Provider Demographics
NPI:1699784181
Name:MCDERMOTT, MARTIN DANIEL (MD)
Entity type:Individual
Prefix:
First Name:MARTIN
Middle Name:DANIEL
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 1:327 PARK AVE
Mailing Address - Street 2:
Mailing Address - City:FORT LUPTON
Mailing Address - State:CO
Mailing Address - Zip Code:80621-1929
Mailing Address - Country:US
Mailing Address - Phone:303-857-2711
Mailing Address - Fax:303-857-1408
Practice Address - Street 1:327 PARK AVE
Practice Address - Street 2:
Practice Address - City:FORT LUPTON
Practice Address - State:CO
Practice Address - Zip Code:80621-1929
Practice Address - Country:US
Practice Address - Phone:303-857-2711
Practice Address - Fax:303-857-1408
Is Sole Proprietor?:No
Enumeration Date:2006-08-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO27735207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO01277359Medicaid
D15370Medicare UPIN
CO422018Medicare ID - Type Unspecified