Provider Demographics
NPI:1285206987
Name:MCDERMOTT, COURTNEY (OD)
Entity Type:Individual
Prefix:
First Name:COURTNEY
Middle Name:
Last Name:MCDERMOTT
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1756 BROOKSIDE AVE
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46201-1018
Mailing Address - Country:US
Mailing Address - Phone:317-213-6614
Mailing Address - Fax:
Practice Address - Street 1:1601 W LINCOLN RD
Practice Address - Street 2:
Practice Address - City:KOKOMO
Practice Address - State:IN
Practice Address - Zip Code:46902-3275
Practice Address - Country:US
Practice Address - Phone:765-453-5696
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-07-13
Last Update Date:2021-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN18004290A152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist