Provider Demographics
NPI:1841239514
Name:BERTOCCI, PAUL VINCENT (MD)
Entity Type:Individual
Prefix:
First Name:PAUL
Middle Name:VINCENT
Last Name:BERTOCCI
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:786 COLLEGE PARKWAY
Mailing Address - Street 2:MAPLE LEAF TREATMENT CENTER
Mailing Address - City:COLCHESTER
Mailing Address - State:VT
Mailing Address - Zip Code:05446
Mailing Address - Country:US
Mailing Address - Phone:802-899-2911
Mailing Address - Fax:802-899-2327
Practice Address - Street 1:786 COLLEGE PARKWAY
Practice Address - Street 2:MAPLE LEAF TREATMENT CENTER
Practice Address - City:COLCHESTER
Practice Address - State:VT
Practice Address - Zip Code:05446
Practice Address - Country:US
Practice Address - Phone:802-899-2911
Practice Address - Fax:802-899-2327
Is Sole Proprietor?:No
Enumeration Date:2006-06-06
Last Update Date:2016-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT0420005481207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
VT0004599Medicaid
VT0004599Medicaid
VTBX3916Medicare PIN