Provider Demographics
NPI:1700917077
Name:JIMERSON, ROBERT CHARLES (MD)
Entity Type:Individual
Prefix:
First Name:ROBERT
Middle Name:CHARLES
Last Name:JIMERSON
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 1:221 ROSCOE RD
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:VT
Mailing Address - Zip Code:05445-9175
Mailing Address - Country:US
Mailing Address - Phone:802-425-2497
Mailing Address - Fax:
Practice Address - Street 1:89 MAIN ST
Practice Address - Street 2:
Practice Address - City:MIDDLEBURY
Practice Address - State:VT
Practice Address - Zip Code:05753-1459
Practice Address - Country:US
Practice Address - Phone:802-388-6751
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-03-08
Last Update Date:2012-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT04200062572084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
VT0004518Medicaid
VTVT4518OtherMEDICARE ID - TYPE UNSPECIFIED