Provider Demographics
NPI:1770682106
Name:TATUM, MIRIAM BLODGETT (MD)
Entity Type:Individual
Prefix:DR
First Name:MIRIAM
Middle Name:BLODGETT
Last Name:TATUM
Suffix:
Gender:F
Credentials:MD
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 970
Mailing Address - Street 2:159 MAIN STREET
Mailing Address - City:DERBY LINE
Mailing Address - State:VT
Mailing Address - Zip Code:05830-0970
Mailing Address - Country:US
Mailing Address - Phone:802-873-3009
Mailing Address - Fax:
Practice Address - Street 1:159 MAIN STREET
Practice Address - Street 2:
Practice Address - City:DERBY LINE
Practice Address - State:VT
Practice Address - Zip Code:05830
Practice Address - Country:US
Practice Address - Phone:802-873-3009
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-09-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT042-00083702080A0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080A0000XAllopathic & Osteopathic PhysiciansPediatricsAdolescent Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
VT042-0008370OtherSTATE LICENSE NUMBER
VT0VN0264Medicaid
VT042-0008370OtherSTATE LICENSE NUMBER
VT0VN0264Medicaid