Healthcare Provider Details

I. General information

NPI: 1750365102
Provider Name (Legal Business Name): MICHAEL JAMES MCDERMOTT M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/30/2005
Last Update Date: 10/08/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1405 MONTGOMERY DR
SANTA ROSA CA
95405-4557
US

IV. Provider business mailing address

1405 MONTGOMERY DR
SANTA ROSA CA
95405-4557
US

V. Phone/Fax

Practice location:
  • Phone: 707-546-1922
  • Fax: 707-546-1897
Mailing address:
  • Phone: 707-546-1922
  • Fax: 707-546-1897

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License NumberG73655
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code207XX0005X
TaxonomySports Medicine (Orthopaedic Surgery) Physician
License NumberG73655
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: