Basic Information
| Provider Information | |||||||||
| NPI: | 1518168814 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MASHKURI | ||||||||
| FirstName: | JAVAD | ||||||||
| MiddleName: | SCOTT | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 547 | ||||||||
| Address2: | ATT: CVMC FINANCE DEPT | ||||||||
| City: | BARRE | ||||||||
| State: | VT | ||||||||
| PostalCode: | 056410547 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8023714263 | ||||||||
| FaxNumber: | 8023714481 | ||||||||
| Practice Location | |||||||||
| Address1: | 130 FISHER RD | ||||||||
| Address2: | ATT: CENTRAL VT MEDICAL CENTER | ||||||||
| City: | BERLIN | ||||||||
| State: | VT | ||||||||
| PostalCode: | 056029516 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8023714263 | ||||||||
| FaxNumber: | 8023714481 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/31/2007 | ||||||||
| LastUpdateDate: | 05/20/2014 | ||||||||
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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 | 146D00000X | MD21838 | OR | N | Emergency Medical Service Providers | Personal Emergency Response Attendant | 207P00000X | 042.0012128 | VT | Y | Allopathic & Osteopathic Physicians | Emergency Medicine |
ID Information
| ID | Type | State | Issuer | Description | 1018668 | 05 | VT | MEDICAID | 134264 | 05 | OR | MEDICAID | 002503501 | 01 | VT | MEDICARE PTAN LINKED TO CVMC-ER | OTHER |