Provider Demographics
NPI:1316026719
Name:VERMONT, THEO (MD)
Entity Type:Individual
Prefix:
First Name:THEO
Middle Name:
Last Name:VERMONT
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1792 TRIBUTE RD
Mailing Address - Street 2:SUITE 350
Mailing Address - City:SACRAMENTO
Mailing Address - State:CA
Mailing Address - Zip Code:95815-4305
Mailing Address - Country:US
Mailing Address - Phone:916-924-6400
Mailing Address - Fax:916-648-0196
Practice Address - Street 1:3160 FOLSOM BLVD
Practice Address - Street 2:
Practice Address - City:SACRAMENTO
Practice Address - State:CA
Practice Address - Zip Code:95816-5219
Practice Address - Country:US
Practice Address - Phone:916-733-3333
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-11-04
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG508402084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G508400Medicaid
CA00G508400OtherBLUE SHIELD
CA90061964OtherPACIFICARE
CAMCMG380400OtherWESTERN HEALTH ADVANTAGE
CA5979420OtherAETNA
CA920643OtherFIRST HEALTH
CA000810823553OtherPHCS
CA6420371OtherCIGNA
CAG50840OtherBLUE CROSS
CA55424OtherGREAT WEST
CA44556OtherINTERPLAN
CA44556OtherINTERPLAN
CA00G508400Medicaid