Provider Demographics
NPI:1598754012
Name:FLYNN, DEDRA M (MD)
Entity Type:Individual
Prefix:
First Name:DEDRA
Middle Name:M
Last Name:FLYNN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:104 PORTER DR
Mailing Address - Street 2:
Mailing Address - City:MIDDLEBURY
Mailing Address - State:VT
Mailing Address - Zip Code:05753-8527
Mailing Address - Country:US
Mailing Address - Phone:802-388-8808
Mailing Address - Fax:802-388-8322
Practice Address - Street 1:1330 EXCHANGE ST
Practice Address - Street 2:SUITE 201
Practice Address - City:MIDDLEBURY
Practice Address - State:VT
Practice Address - Zip Code:05753-4464
Practice Address - Country:US
Practice Address - Phone:802-388-7959
Practice Address - Fax:802-388-8136
Is Sole Proprietor?:No
Enumeration Date:2005-10-18
Last Update Date:2013-12-26
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
VT0420010996208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02681818Medicaid
VT1011760Medicaid
NY02681818Medicaid