Provider Demographics
NPI:1083680599
Name:MCDERMOTT, MARK T (OD)
Entity Type:Individual
Prefix:DR
First Name:MARK
Middle Name:T
Last Name:MCDERMOTT
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2353 RICE ST
Mailing Address - Street 2:STE. 206
Mailing Address - City:ROSEVILLE
Mailing Address - State:MN
Mailing Address - Zip Code:55113-3739
Mailing Address - Country:US
Mailing Address - Phone:651-483-8148
Mailing Address - Fax:651-483-3206
Practice Address - Street 1:2353 RICE ST
Practice Address - Street 2:STE 206
Practice Address - City:ROSEVILLE
Practice Address - State:MN
Practice Address - Zip Code:55113
Practice Address - Country:US
Practice Address - Phone:651-483-8148
Practice Address - Fax:651-483-3206
Is Sole Proprietor?:No
Enumeration Date:2006-02-24
Last Update Date:2008-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN2594152W00000X
IA02169152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN22 07646OtherMEDICA
MN26613OtherHEALTH PARTNERS
MN152713400Medicaid
MN615152747OtherMETROPOLITAN HEALTH PLAN
MN124899OtherU CARE
MN57D32MCOtherBLUE CROSS BLUE SHIELD
06426800001Medicare NSC
MN22 07646OtherMEDICA
410001052Medicare ID - Type Unspecified
410037349Medicare ID - Type UnspecifiedRAILROAD MEDICARE