Provider Demographics
NPI:1902870975
Name:HASELTON, CYNTHIA AMES (MD)
Entity Type:Individual
Prefix:
First Name:CYNTHIA
Middle Name:AMES
Last Name:HASELTON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:600 BLAIR PARK RD
Mailing Address - Street 2:SUITE 190
Mailing Address - City:WILLISTON
Mailing Address - State:VT
Mailing Address - Zip Code:05495-7586
Mailing Address - Country:US
Mailing Address - Phone:802-288-1145
Mailing Address - Fax:802-872-0282
Practice Address - Street 1:789 PINE ST
Practice Address - Street 2:
Practice Address - City:BURLINGTON
Practice Address - State:VT
Practice Address - Zip Code:05401-4933
Practice Address - Country:US
Practice Address - Phone:802-864-0693
Practice Address - Fax:802-860-6613
Is Sole Proprietor?:No
Enumeration Date:2006-02-15
Last Update Date:2010-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT042-0009288207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
VTOVN1604Medicaid
VTVN2003Medicare PIN
G51372Medicare UPIN