Provider Demographics
NPI:1588685218
Name:KNOWLTON, ROGER H (DO)
Entity Type:Individual
Prefix:
First Name:ROGER
Middle Name:H
Last Name:KNOWLTON
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 547
Mailing Address - Street 2:CENTRAL VERMONT MEDICAL CENTER - FINANCE DEPT
Mailing Address - City:BARRE
Mailing Address - State:VT
Mailing Address - Zip Code:05641-0547
Mailing Address - Country:US
Mailing Address - Phone:802-371-5961
Mailing Address - Fax:802-371-5960
Practice Address - Street 1:130 FISHER RD
Practice Address - Street 2:MOB-A SUITE 1-4
Practice Address - City:BERLIN
Practice Address - State:VT
Practice Address - Zip Code:05602-9516
Practice Address - Country:US
Practice Address - Phone:802-371-5961
Practice Address - Fax:802-371-5960
Is Sole Proprietor?:No
Enumeration Date:2006-07-21
Last Update Date:2014-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT032-0000288207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
VT0005632Medicaid
E69521Medicare UPIN
VT0005632Medicaid
VT0005632Medicaid