Individual
DR. MIRIAM BLODGETT TATUM
Active
Sole proprietor
No
Provider details
NPI number
Gender
F
Credential
M.D.
Contact information
Practice address
159 MAIN STREET, DERBY LINE, VT 05830
(802) 873-3009
Mailing address
PO BOX 970, 159 MAIN STREET, DERBY LINE, VT 05830-0970
(802) 873-3009
Taxonomy
Speciality
Code
Description
License number
State
2080A0000X
Pediatric Adolescent Medicine Physician
Primary
042-0008370
VT
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
042-0008370
STATE LICENSE NUMBER
VT
05
—
0VN0264
—
VT
Enumeration date
09/22/2006
Last updated
07/08/2007
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