Provider Demographics
NPI:1487397774
Name:MCDERMOTT, JOHN JOSEPH IV
Entity type:Individual
Prefix:
First Name:JOHN
Middle Name:JOSEPH
Last Name:MCDERMOTT
Suffix:IV
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1238 BRUNSWICK LN
Mailing Address - Street 2:
Mailing Address - City:VENTURA
Mailing Address - State:CA
Mailing Address - Zip Code:93001-4036
Mailing Address - Country:US
Mailing Address - Phone:805-889-3997
Mailing Address - Fax:
Practice Address - Street 1:6431 FANNIN STREET, MSB 1.134
Practice Address - Street 2:
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77030
Practice Address - Country:US
Practice Address - Phone:713-500-6526
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-04-15
Last Update Date:2022-05-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program