Provider Demographics
NPI:1467448613
Name:MAWHINNEY, BRIAN J (OD)
Entity type:Individual
Prefix:
First Name:BRIAN
Middle Name:J
Last Name:MAWHINNEY
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1290 HOSPITAL DR
Mailing Address - Street 2:SUITE 5
Mailing Address - City:SAINT JOHNSBURY
Mailing Address - State:VT
Mailing Address - Zip Code:05819-9205
Mailing Address - Country:US
Mailing Address - Phone:802-748-8126
Mailing Address - Fax:802-748-2208
Practice Address - Street 1:1290 HOSPITAL DR
Practice Address - Street 2:SUITE 5
Practice Address - City:ST JOHNSBURY
Practice Address - State:VT
Practice Address - Zip Code:05819-9239
Practice Address - Country:US
Practice Address - Phone:802-748-8126
Practice Address - Fax:802-748-2208
Is Sole Proprietor?:No
Enumeration Date:2005-09-23
Last Update Date:2016-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT0300000333152W00000X
NH0770152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
VT1010971Medicaid
NH30353214Medicaid
VT1010971Medicaid
NH30353214Medicaid
U87223Medicare UPIN