Provider Demographics
NPI:1437184637
Name:JIMMO, BRAD LEE (MD)
Entity Type:Individual
Prefix:
First Name:BRAD
Middle Name:LEE
Last Name:JIMMO
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 1:215 STRATTON RD
Mailing Address - Street 2:
Mailing Address - City:RUTLAND
Mailing Address - State:VT
Mailing Address - Zip Code:05701-4621
Mailing Address - Country:US
Mailing Address - Phone:802-775-7745
Mailing Address - Fax:802-775-5155
Practice Address - Street 1:215 STRATTON RD
Practice Address - Street 2:
Practice Address - City:RUTLAND
Practice Address - State:VT
Practice Address - Zip Code:05701-4621
Practice Address - Country:US
Practice Address - Phone:802-775-7745
Practice Address - Fax:802-775-5155
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-12
Last Update Date:2012-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT042-0010388208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
VT1008803Medicaid
VT1008803Medicaid
VTVN2888Medicare ID - Type Unspecified