Provider Demographics
NPI:1154387538
Name:MCDERMOTT, DUSTIN MAX (MD)
Entity type:Individual
Prefix:
First Name:DUSTIN
Middle Name:MAX
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:PO BOX 4207
Mailing Address - Street 2:
Mailing Address - City:LONGVIEW
Mailing Address - State:TX
Mailing Address - Zip Code:75606-4207
Mailing Address - Country:US
Mailing Address - Phone:903-315-2762
Mailing Address - Fax:903-315-2595
Practice Address - Street 1:703 E MARSHALL AVE
Practice Address - Street 2:SUITE 3000
Practice Address - City:LONGVIEW
Practice Address - State:TX
Practice Address - Zip Code:75601-5500
Practice Address - Country:US
Practice Address - Phone:903-315-2762
Practice Address - Fax:903-315-2595
Is Sole Proprietor?:No
Enumeration Date:2006-04-25
Last Update Date:2023-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01060359A208600000X
TXN3172208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
INP00923240OtherRAILROAD MEDICARE
INP00923240OtherRAILROAD MEDICARE
IN859910F6Medicare PIN
IN265130MMMMedicare PIN