Provider Demographics
NPI:1588605307
Name:PRICE, MARK JOHN (MD)
Entity Type:Individual
Prefix:DR
First Name:MARK
Middle Name:JOHN
Last Name:PRICE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:97 SHERMAN DRIVE
Mailing Address - Street 2:
Mailing Address - City:SAINT JOHNSBURY
Mailing Address - State:VT
Mailing Address - Zip Code:05819
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:97 SHERMAN DR
Practice Address - Street 2:ST. JOHNSBURY PEDIATRICS
Practice Address - City:SAINT JOHNSBURY
Practice Address - State:VT
Practice Address - Zip Code:05819-9280
Practice Address - Country:US
Practice Address - Phone:802-748-5131
Practice Address - Fax:802-748-4237
Is Sole Proprietor?:No
Enumeration Date:2006-06-10
Last Update Date:2013-06-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT042-0007199208000000X
NH7466208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
NH3072326Medicaid
VT0006490Medicaid
VTVT6490Medicare PIN
VTC65721Medicare UPIN