Provider Demographics
NPI:1922102292
Name:MCCORMACK, WILLIAM J (MD, PA)
Entity Type:Individual
Prefix:
First Name:WILLIAM
Middle Name:J
Last Name:MCCORMACK
Suffix:
Gender:M
Credentials:MD, PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:275 18TH STREET
Mailing Address - Street 2:SUITE 103
Mailing Address - City:VERO BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32960-0824
Mailing Address - Country:US
Mailing Address - Phone:772-567-6181
Mailing Address - Fax:772-567-8242
Practice Address - Street 1:275 18TH STREET
Practice Address - Street 2:SUITE 103
Practice Address - City:VERO BEACH
Practice Address - State:FL
Practice Address - Zip Code:32960-0824
Practice Address - Country:US
Practice Address - Phone:772-567-6181
Practice Address - Fax:772-567-8242
Is Sole Proprietor?:No
Enumeration Date:2006-09-08
Last Update Date:2009-01-23
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
FLME0059271207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL052486700Medicaid
FL052486700Medicaid
11899Medicare ID - Type Unspecified