Provider Demographics
NPI:1750365102
Name:MCDERMOTT, MICHAEL JAMES (MD)
Entity type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:JAMES
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 1:1405 MONTGOMERY DR
Mailing Address - Street 2:
Mailing Address - City:SANTA ROSA
Mailing Address - State:CA
Mailing Address - Zip Code:95405-4557
Mailing Address - Country:US
Mailing Address - Phone:707-546-1922
Mailing Address - Fax:707-546-1897
Practice Address - Street 1:1405 MONTGOMERY DR
Practice Address - Street 2:
Practice Address - City:SANTA ROSA
Practice Address - State:CA
Practice Address - Zip Code:95405-4557
Practice Address - Country:US
Practice Address - Phone:707-546-1922
Practice Address - Fax:707-546-1897
Is Sole Proprietor?:No
Enumeration Date:2005-11-30
Last Update Date:2014-10-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG73655207X00000X, 207XX0005X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
No207XX0005XAllopathic & Osteopathic PhysiciansOrthopaedic SurgerySports Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G736550Medicaid
CA00G736553OtherCIGNA DME
CAG73655OtherLICENSE
CAG73655OtherLICENSE
CAP00391906Medicare PIN
CA00G736553OtherCIGNA DME