Provider Demographics
NPI:1942226121
Name:BOLDUC, ALLYSON M (MD)
Entity Type:Individual
Prefix:DR
First Name:ALLYSON
Middle Name:M
Last Name:BOLDUC
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 1:1775 WILLISTON RD
Mailing Address - Street 2:
Mailing Address - City:SOUTH BURLINGTON
Mailing Address - State:VT
Mailing Address - Zip Code:05403-6491
Mailing Address - Country:US
Mailing Address - Phone:802-847-8500
Mailing Address - Fax:802-847-6140
Practice Address - Street 1:1775 WILLISTON RD
Practice Address - Street 2:
Practice Address - City:SOUTH BURLINGTON
Practice Address - State:VT
Practice Address - Zip Code:05403-6491
Practice Address - Country:US
Practice Address - Phone:802-847-8500
Practice Address - Fax:802-847-6140
Is Sole Proprietor?:No
Enumeration Date:2006-07-14
Last Update Date:2010-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT420009468207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01812995Medicaid
VTOVN1199Medicaid
VTBOVN1199Medicare ID - Type Unspecified
VTG09969Medicare UPIN