Provider Demographics
NPI:1598278137
Name:GREEN MOUNTAIN PLASTIC AND RECONSTRUCTIVE SURGERY
Entity Type:Organization
Organization Name:GREEN MOUNTAIN PLASTIC AND RECONSTRUCTIVE SURGERY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:DONALD
Authorized Official - Middle Name:R
Authorized Official - Last Name:LAUB
Authorized Official - Suffix:JR
Authorized Official - Credentials:MD
Authorized Official - Phone:802-598-9619
Mailing Address - Street 1:354 MOUNTAIN VIEW DR STE 300
Mailing Address - Street 2:
Mailing Address - City:COLCHESTER
Mailing Address - State:VT
Mailing Address - Zip Code:05446-5988
Mailing Address - Country:US
Mailing Address - Phone:802-864-0192
Mailing Address - Fax:802-860-4919
Practice Address - Street 1:354 MOUNTAIN VIEW DR STE 300
Practice Address - Street 2:
Practice Address - City:COLCHESTER
Practice Address - State:VT
Practice Address - Zip Code:05446-5988
Practice Address - Country:US
Practice Address - Phone:802-864-0192
Practice Address - Fax:802-860-4919
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-11-06
Last Update Date:2017-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT42-0008887208200000X, 2082S0105X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208200000XAllopathic & Osteopathic PhysiciansPlastic SurgeryGroup - Single Specialty
No2082S0105XAllopathic & Osteopathic PhysiciansPlastic SurgerySurgery of the HandGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
VTOVN1072Medicaid