Provider Demographics
NPI:1174507370
Name:DEMOTT, MEGAN C (MD)
Entity Type:Individual
Prefix:
First Name:MEGAN
Middle Name:C
Last Name:DEMOTT
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5984 LA JOLLA CORONA DR
Mailing Address - Street 2:
Mailing Address - City:LA JOLLA
Mailing Address - State:CA
Mailing Address - Zip Code:92037-7447
Mailing Address - Country:US
Mailing Address - Phone:503-490-8067
Mailing Address - Fax:
Practice Address - Street 1:5984 LA JOLLA CORONA DR
Practice Address - Street 2:
Practice Address - City:LA JOLLA
Practice Address - State:CA
Practice Address - Zip Code:92037-7447
Practice Address - Country:US
Practice Address - Phone:503-490-8067
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-12-01
Last Update Date:2011-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA96269207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A962690Medicaid
CA1174507370Medicaid
CA1174507370Medicaid
CAWA96269AMedicare PIN
I31029Medicare UPIN