Provider Demographics
NPI:1205928264
Name:MARTIN MCDERMOTT MD PC
Entity type:Organization
Organization Name:MARTIN MCDERMOTT MD PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:MARTIN
Authorized Official - Middle Name:DANIEL
Authorized Official - Last Name:MCDERMOTT
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:303-857-2711
Mailing Address - Street 1:327 PARK AVE
Mailing Address - Street 2:
Mailing Address - City:FORT LUPTON
Mailing Address - State:CO
Mailing Address - Zip Code:80621-1929
Mailing Address - Country:US
Mailing Address - Phone:303-857-2711
Mailing Address - Fax:303-857-1408
Practice Address - Street 1:327 PARK AVE
Practice Address - Street 2:
Practice Address - City:FORT LUPTON
Practice Address - State:CO
Practice Address - Zip Code:80621-1929
Practice Address - Country:US
Practice Address - Phone:303-857-2711
Practice Address - Fax:303-857-1408
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-28
Last Update Date:2008-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO76628205Medicaid
COC422008Medicare PIN
CO0979420001Medicare NSC