Provider Demographics
NPI:1750341780
Name:MCCORMACK, JOHN L (MD)
Entity type:Individual
Prefix:
First Name:JOHN
Middle Name:L
Last Name:MCCORMACK
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Last Name:
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Mailing Address - Street 1:4755 OGLETOWN STANTON RD
Mailing Address - Street 2:DEPARTMENT OF RADIOLOGY
Mailing Address - City:NEWARK
Mailing Address - State:DE
Mailing Address - Zip Code:19718-2200
Mailing Address - Country:US
Mailing Address - Phone:302-733-1806
Mailing Address - Fax:302-733-1808
Practice Address - Street 1:4755 OGLETOWN STANTON RD
Practice Address - Street 2:DEPARTMENT OF RADIOLOGY
Practice Address - City:NEWARK
Practice Address - State:DE
Practice Address - Zip Code:19718-2200
Practice Address - Country:US
Practice Address - Phone:302-733-1806
Practice Address - Fax:302-733-1808
Is Sole Proprietor?:No
Enumeration Date:2006-03-24
Last Update Date:2017-11-13
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
DEC1-00028002085R0202X
PAMD034535E2085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
DE0000111601Medicaid
300074167OtherRAILROAD MEDICARE #
DE013355X70Medicare PIN
DEC48617Medicare UPIN
DE0000111601Medicaid