Basic Information
| Provider Information | |||||||||
| NPI: | 1528032638 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | NASSAU | ||||||||
| FirstName: | ROBERT | ||||||||
| MiddleName: | D | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 600 BLAIR PARK RD | ||||||||
| Address2: | SUITE 190 | ||||||||
| City: | WILLISTON | ||||||||
| State: | VT | ||||||||
| PostalCode: | 054957586 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8022881145 | ||||||||
| FaxNumber: | 8028720282 | ||||||||
| Practice Location | |||||||||
| Address1: | 21 BELMONT AVE | ||||||||
| Address2: | |||||||||
| City: | BRATTLEBORO | ||||||||
| State: | VT | ||||||||
| PostalCode: | 053017110 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8022583905 | ||||||||
| FaxNumber: | 8022584903 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/15/2006 | ||||||||
| LastUpdateDate: | 11/11/2010 | ||||||||
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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 | 042-0004243 | VT | Y | Allopathic & Osteopathic Physicians | Pediatrics |
ID Information
| ID | Type | State | Issuer | Description | 0004376 | 05 | VT | MEDICAID |