Basic Information
| Provider Information | |||||||||
| NPI: | 1093749756 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | LULOFF | ||||||||
| FirstName: | MARTIN | ||||||||
| MiddleName: | R | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 74 GORDONS WAY | ||||||||
| Address2: | |||||||||
| City: | ARLINGTON | ||||||||
| State: | VT | ||||||||
| PostalCode: | 05250 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5084355506 | ||||||||
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| Practice Location | |||||||||
| Address1: | 140 HOSPITAL DR | ||||||||
| Address2: | SUITE 207 | ||||||||
| City: | BENNINGTON | ||||||||
| State: | VT | ||||||||
| PostalCode: | 052015009 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8024473930 | ||||||||
| FaxNumber: | 8024478539 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/10/2006 | ||||||||
| LastUpdateDate: | 10/29/2007 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208000000X | 43877 | MA | Y | Allopathic & Osteopathic Physicians | Pediatrics |
ID Information
| ID | Type | State | Issuer | Description | 12-01279 | 01 | MA | UNITED HEALTHCARE | OTHER | 043877 | 01 | MA | TUFTS | OTHER | 20017 | 01 | MA | HEALTHSOURCE(CMHC) | OTHER | 451063 | 01 | MA | AETNA/US HEALTHCARE | OTHER | E45016 | 01 | MA | BLUE CROSS/BLUE SHIELD | OTHER | 4223701 | 01 | MA | AETNA | OTHER | 20700 | 01 | MA | HARVARD PILGRIM | OTHER | B10096001 | 01 | MA | CIGNA | OTHER | 2072734 | 05 | MA | MEDICAID |