Basic Information
| Provider Information | |||||||||
| NPI: | 1487628608 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BOLDUC | ||||||||
| FirstName: | THOMAS | ||||||||
| MiddleName: | G | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 66 KNIGHT LN STE 10 | ||||||||
| Address2: | |||||||||
| City: | WILLISTON | ||||||||
| State: | VT | ||||||||
| PostalCode: | 054959308 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8028724343 | ||||||||
| FaxNumber: | 8022881144 | ||||||||
| Practice Location | |||||||||
| Address1: | 11 HAYDENBERRY DR UNIT 103 | ||||||||
| Address2: | |||||||||
| City: | MILTON | ||||||||
| State: | VT | ||||||||
| PostalCode: | 054682200 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8028931200 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/14/2006 | ||||||||
| LastUpdateDate: | 03/22/2021 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | M | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 03/22/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208000000X | MD00042058 | WA | N | Allopathic & Osteopathic Physicians | Pediatrics | 208000000X | 0420012746 | VT | Y | Allopathic & Osteopathic Physicians | Pediatrics |
ID Information
| ID | Type | State | Issuer | Description | 8364523 | 05 | WA | MEDICAID | 0420012746 | 01 | VT | MEDICAL LICENSE | OTHER | 172210 | 01 | WA | L&I | OTHER | 299829 | 05 | OR | MEDICAID | P00018622 | 01 | WA | RAIL ROAD MEDICARE | OTHER | 1022471 | 05 | VT | MEDICAID |