Provider Demographics
NPI:1104978659
Name:MCCORMACK, MARY M (RD, LDN)
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:M
Last Name:MCCORMACK
Suffix:
Gender:F
Credentials:RD, LDN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12458 MCGREGOR WOODS CIR
Mailing Address - Street 2:
Mailing Address - City:FORT MYERS
Mailing Address - State:FL
Mailing Address - Zip Code:33908-2459
Mailing Address - Country:US
Mailing Address - Phone:239-454-4466
Mailing Address - Fax:
Practice Address - Street 1:12458 MCGREGOR WOODS CIR
Practice Address - Street 2:
Practice Address - City:FORT MYERS
Practice Address - State:FL
Practice Address - Zip Code:33908-2459
Practice Address - Country:US
Practice Address - Phone:239-454-4466
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-17
Last Update Date:2008-09-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLND86133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLN0118BMedicare PIN