Healthcare Provider Details

I. General information

NPI: 1033075601
Provider Name (Legal Business Name): EZRA DEMERS
Entity Type: Individual
Gender:
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/29/2025
Last Update Date: 09/11/2026
Certification Date: 09/11/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

174 HOSPITAL LOOP
BERLIN VT
05602-9105
US

IV. Provider business mailing address

PO BOX 647
MONTPELIER VT
05601-0647
US

V. Phone/Fax

Practice location:
  • Phone: 802-479-4083
  • Fax: 802-476-1476
Mailing address:
  • Phone: 802-479-4083
  • Fax: 802-476-1476

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number097.0136421
License Number StateVT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: