Provider Demographics
NPI:1639136559
Name:MAYER, JACK LAWRENCE (MD, FAAP)
Entity Type:Individual
Prefix:DR
First Name:JACK
Middle Name:LAWRENCE
Last Name:MAYER
Suffix:
Gender:M
Credentials:MD, FAAP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:44 COLLINS DR
Mailing Address - Street 2:SUITE 202
Mailing Address - City:MIDDLEBURY
Mailing Address - State:VT
Mailing Address - Zip Code:05753-8528
Mailing Address - Country:US
Mailing Address - Phone:802-388-1338
Mailing Address - Fax:802-388-8244
Practice Address - Street 1:44 COLLINS DR
Practice Address - Street 2:SUITE 202
Practice Address - City:MIDDLEBURY
Practice Address - State:VT
Practice Address - Zip Code:05753-8528
Practice Address - Country:US
Practice Address - Phone:802-388-1338
Practice Address - Fax:802-388-8244
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-04-26
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT042-00047282080A0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080A0000XAllopathic & Osteopathic PhysiciansPediatricsAdolescent Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
VT0004626Medicaid
26P885OtherMVP ID#
VT4626OtherBCVT
C65457Medicare UPIN