Provider Demographics
NPI:1578523825
Name:MCDERMOTT, WAYNE MICHAEL (MD)
Entity Type:Individual
Prefix:
First Name:WAYNE
Middle Name:MICHAEL
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 1:1543 AMBERLEY FOREST ROAD
Mailing Address - Street 2:
Mailing Address - City:VIRGINIA BEACH
Mailing Address - State:VA
Mailing Address - Zip Code:23453
Mailing Address - Country:US
Mailing Address - Phone:757-471-7700
Mailing Address - Fax:757-471-9541
Practice Address - Street 1:1543 AMBERLEY FOREST ROAD
Practice Address - Street 2:
Practice Address - City:VIRGINIA BEACH
Practice Address - State:VA
Practice Address - Zip Code:23453
Practice Address - Country:US
Practice Address - Phone:757-471-7700
Practice Address - Fax:757-471-9541
Is Sole Proprietor?:Yes
Enumeration Date:2006-03-23
Last Update Date:2007-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101037511208600000X, 208C00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208C00000XAllopathic & Osteopathic PhysiciansColon & Rectal Surgery
No208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA056754OtherANTHEM
VA056754OtherANTHEM