Provider Demographics
NPI:1326085820
Name:MCDERMOTT, MARK LEO (MD)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:LEO
Last Name:MCDERMOTT
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1560 EAST MAPLE ROAD
Mailing Address - Street 2:SUITE 400-CREDENTIALING
Mailing Address - City:TROY
Mailing Address - State:MI
Mailing Address - Zip Code:48083-1189
Mailing Address - Country:US
Mailing Address - Phone:248-581-5976
Mailing Address - Fax:248-581-5640
Practice Address - Street 1:KRESGE EYE INSTITUTE
Practice Address - Street 2:4717 ST ANTOINE
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48201
Practice Address - Country:US
Practice Address - Phone:313-577-8900
Practice Address - Fax:313-577-0700
Is Sole Proprietor?:No
Enumeration Date:2006-06-01
Last Update Date:2016-05-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301054291207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI0P30630096Medicare PIN