Provider Demographics
NPI:1437253655
Name:MCCORMICK, DAVID J (PAC)
Entity Type:Individual
Prefix:
First Name:DAVID
Middle Name:J
Last Name:MCCORMICK
Suffix:
Gender:M
Credentials:PAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:51 EVERGREEN CT
Mailing Address - Street 2:
Mailing Address - City:WAKEFIELD
Mailing Address - State:RI
Mailing Address - Zip Code:02879-1652
Mailing Address - Country:US
Mailing Address - Phone:401-789-1734
Mailing Address - Fax:
Practice Address - Street 1:220 ROUTE 12
Practice Address - Street 2:
Practice Address - City:GROTON
Practice Address - State:CT
Practice Address - Zip Code:06340-3414
Practice Address - Country:US
Practice Address - Phone:860-446-6137
Practice Address - Fax:860-446-6143
Is Sole Proprietor?:No
Enumeration Date:2006-09-08
Last Update Date:2019-05-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RIPA00249363AM0700X
CT4265363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
RIP21680Medicare UPIN
RI979005320Medicare PIN