Provider Demographics
NPI:1346357852
Name:MCDERMOTT, SHAWN JAMES (DC)
Entity Type:Individual
Prefix:DR
First Name:SHAWN
Middle Name:JAMES
Last Name:MCDERMOTT
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:86 DYLAN DR
Mailing Address - Street 2:SUITE 1
Mailing Address - City:RANDOLPH
Mailing Address - State:VT
Mailing Address - Zip Code:05060-9619
Mailing Address - Country:US
Mailing Address - Phone:802-728-5159
Mailing Address - Fax:802-728-5199
Practice Address - Street 1:86 DYLAN DR
Practice Address - Street 2:SUITE 1
Practice Address - City:RANDOLPH
Practice Address - State:VT
Practice Address - Zip Code:05060-9619
Practice Address - Country:US
Practice Address - Phone:802-728-5159
Practice Address - Fax:802-728-5199
Is Sole Proprietor?:No
Enumeration Date:2006-08-23
Last Update Date:2008-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT0060001016111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
VTOVN1716Medicaid
VT38057OtherBLUECROSS BLUESHEILD VT
VTVN1716Medicare ID - Type Unspecified
VTOVN1716Medicaid