Provider Demographics
NPI:1750393211
Name:BARCELOW, JERRY ALBERT
Entity type:Individual
Prefix:
First Name:JERRY
Middle Name:ALBERT
Last Name:BARCELOW
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1593 VT RTE 107
Mailing Address - Street 2:
Mailing Address - City:BETHEL
Mailing Address - State:VT
Mailing Address - Zip Code:05032-4456
Mailing Address - Country:US
Mailing Address - Phone:802-234-9728
Mailing Address - Fax:802-234-9732
Practice Address - Street 1:1593 VT RTE 107
Practice Address - Street 2:
Practice Address - City:BETHEL
Practice Address - State:VT
Practice Address - Zip Code:05032-4456
Practice Address - Country:US
Practice Address - Phone:802-234-9728
Practice Address - Fax:802-234-9732
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-13
Last Update Date:2014-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT300000196152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
VT0006624Medicaid
VTT25381Medicare UPIN
VTVT662401Medicare PIN