Provider Demographics
NPI:1114244142
Name:MCDERMOTT, BRIAN WILLIAM (DPM)
Entity Type:Individual
Prefix:
First Name:BRIAN
Middle Name:WILLIAM
Last Name:MCDERMOTT
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1010 N BANCROFT PKWY
Mailing Address - Street 2:STE 12
Mailing Address - City:WILMINGTON
Mailing Address - State:DE
Mailing Address - Zip Code:19805-2690
Mailing Address - Country:US
Mailing Address - Phone:302-658-1129
Mailing Address - Fax:
Practice Address - Street 1:1010 N BANCROFT PKWY
Practice Address - Street 2:STE 12
Practice Address - City:WILMINGTON
Practice Address - State:DE
Practice Address - Zip Code:19805-2690
Practice Address - Country:US
Practice Address - Phone:302-658-1129
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-04-30
Last Update Date:2019-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DEE1-0000227213ES0103X, 213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
No213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
DE1114244142Medicaid