Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 207V00000X | Obstetrician & Gynecologist | 042-0005310 | VT |
NPI | 1003993486 |
---|---|
Provider Name | Dr. John Matheson Mclellan |
First Address | Bennington, VT 05201-5009 |
Second Address | Bennington, VT 05201-5009 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 01/11/2006 |
Last Update Date | 30/04/2008 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
0004563 | (05) | VT |
03-0354915 | TAX ID (01) | VT |
E40751 | (02) | VT |