Provider Demographics
NPI:1033178637
Name:MCCORMACK, MARIE MONIQUE (MD)
Entity Type:Individual
Prefix:DR
First Name:MARIE
Middle Name:MONIQUE
Last Name:MCCORMACK
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:MARIE
Other - Middle Name:M
Other - Last Name:FORRED
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:1155 MILL ST # MCM14
Mailing Address - Street 2:
Mailing Address - City:RENO
Mailing Address - State:NV
Mailing Address - Zip Code:89502-1576
Mailing Address - Country:US
Mailing Address - Phone:775-982-5262
Mailing Address - Fax:775-982-3900
Practice Address - Street 1:5575 KIETZKE LN
Practice Address - Street 2:
Practice Address - City:RENO
Practice Address - State:NV
Practice Address - Zip Code:89511-2290
Practice Address - Country:US
Practice Address - Phone:775-851-1505
Practice Address - Fax:775-851-1583
Is Sole Proprietor?:No
Enumeration Date:2006-03-22
Last Update Date:2021-05-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV9936207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
11041134OtherCAQH
11041134OtherCAQH
NVV102271Medicare PIN