Basic Information
| Provider Information | |||||||||
| NPI: | 1316026719 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | VERMONT | ||||||||
| FirstName: | THEO | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1792 TRIBUTE RD | ||||||||
| Address2: | SUITE 350 | ||||||||
| City: | SACRAMENTO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 958154305 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9169246400 | ||||||||
| FaxNumber: | 9166480196 | ||||||||
| Practice Location | |||||||||
| Address1: | 3160 FOLSOM BLVD | ||||||||
| Address2: | |||||||||
| City: | SACRAMENTO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 958165219 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9167333333 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 11/04/2006 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2084P0800X | G50840 | CA | Y | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Psychiatry |
ID Information
| ID | Type | State | Issuer | Description | 00G508400 | 05 | CA | MEDICAID | 00G508400 | 01 | CA | BLUE SHIELD | OTHER | 90061964 | 01 | CA | PACIFICARE | OTHER | MCMG380400 | 01 | CA | WESTERN HEALTH ADVANTAGE | OTHER | 5979420 | 01 | CA | AETNA | OTHER | 920643 | 01 | CA | FIRST HEALTH | OTHER | 000810823553 | 01 | CA | PHCS | OTHER | 6420371 | 01 | CA | CIGNA | OTHER | G50840 | 01 | CA | BLUE CROSS | OTHER | 55424 | 01 | CA | GREAT WEST | OTHER | 44556 | 01 | CA | INTERPLAN | OTHER |