Provider Demographics
NPI:1679595094
Name:BOSENBERG, MARCUS (MD, PHD)
Entity type:Individual
Prefix:DR
First Name:MARCUS
Middle Name:
Last Name:BOSENBERG
Suffix:
Gender:M
Credentials:MD, PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:460 MARTEL LN
Mailing Address - Street 2:
Mailing Address - City:ST GEORGE
Mailing Address - State:VT
Mailing Address - Zip Code:05495-7087
Mailing Address - Country:US
Mailing Address - Phone:802-878-0917
Mailing Address - Fax:
Practice Address - Street 1:111 COLCHESTER AVE
Practice Address - Street 2:
Practice Address - City:BURLINGTON
Practice Address - State:VT
Practice Address - Zip Code:05401-1473
Practice Address - Country:US
Practice Address - Phone:802-847-9447
Practice Address - Fax:802-847-9644
Is Sole Proprietor?:No
Enumeration Date:2006-07-24
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT042-0010348207ZD0900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ZD0900XAllopathic & Osteopathic PhysiciansPathologyDermatopathology
Provider Identifiers
StateIdentifier IDID TypeIssuer
VT1008503Medicaid
VTVN2814Medicare ID - Type Unspecified
VT1008503Medicaid