Provider Demographics
NPI:1356324008
Name:MCDERMOTT, EDWARD J (MD)
Entity Type:Individual
Prefix:DR
First Name:EDWARD
Middle Name:J
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 1:342 MONTAUK AVE
Mailing Address - Street 2:
Mailing Address - City:NEW LONDON
Mailing Address - State:CT
Mailing Address - Zip Code:06320-4726
Mailing Address - Country:US
Mailing Address - Phone:860-460-3236
Mailing Address - Fax:860-442-7270
Practice Address - Street 1:235 LESTERTOWN RD
Practice Address - Street 2:
Practice Address - City:GROTON
Practice Address - State:CT
Practice Address - Zip Code:06340-2808
Practice Address - Country:US
Practice Address - Phone:860-445-7478
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2005-11-28
Last Update Date:2019-05-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT20822174400000X, 207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT030963OtherHEALTH NET
CT001208222Medicaid
CT010020822CT03OtherANTHEM BLUE CROSS
110006406Medicare PIN
CTB84483Medicare UPIN