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Organization
BROOKSIDE PEDIATRICS & ADOLESCENT MEDICINE PLLC
Active
Organization
BROOKSIDE PEDIATRICS & ADOLESCENT MEDICINE PLLC
Active
Organization subpart
No
Provider details
NPI number
Authorized official
THEODORE L JOHNSON MD (OWNER)
(802) 442-2264
Entity
Organization
Contact information
Practice address
194 NORTH STREET, BENNINGTON, VT 05201
(802) 442-2264
(802) 442-2337
Mailing address
194 NORTH STREET, BENNINGTON, VT 05201
(802) 442-2264
(802) 442-2337
Taxonomy
Speciality
Code
Description
License number
State
208000000X
Pediatrics Physician
Primary
—
NULL
208000000X
Pediatrics Physician
Primary
—
—
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
1007123
—
VT
Enumeration date
08/22/2006
Last updated
10/04/2011
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