Provider Demographics
NPI:1457346124
Name:CLATTENBURG, RICHARD N (MD)
Entity Type:Individual
Prefix:
First Name:RICHARD
Middle Name:N
Last Name:CLATTENBURG
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1067 CADY HILL RD
Mailing Address - Street 2:
Mailing Address - City:PERKINSVILLE
Mailing Address - State:VT
Mailing Address - Zip Code:05151-9523
Mailing Address - Country:US
Mailing Address - Phone:802-263-5505
Mailing Address - Fax:802-263-5594
Practice Address - Street 1:1067 CADY HILL RD
Practice Address - Street 2:
Practice Address - City:PERKINSVILLE
Practice Address - State:VT
Practice Address - Zip Code:05151-9523
Practice Address - Country:US
Practice Address - Phone:802-263-5505
Practice Address - Fax:802-263-5594
Is Sole Proprietor?:Yes
Enumeration Date:2005-09-19
Last Update Date:2011-06-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT0420006288146N00000X
VT042-0006288208000000X, 2080P0006X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080P0006XAllopathic & Osteopathic PhysiciansPediatricsDevelopmental - Behavioral Pediatrics
No146N00000XEmergency Medical Service ProvidersEmergency Medical Technician, Basic
No208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
VT0005110Medicaid
VT0005110Medicaid
VTVT5110Medicare ID - Type Unspecified