Healthcare Provider Details

I. General information

NPI: 1699784181
Provider Name (Legal Business Name): MARTIN DANIEL MCDERMOTT M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/05/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

327 PARK AVE
FORT LUPTON CO
80621-1929
US

IV. Provider business mailing address

327 PARK AVE
FORT LUPTON CO
80621-1929
US

V. Phone/Fax

Practice location:
  • Phone: 303-857-2711
  • Fax: 303-857-1408
Mailing address:
  • Phone: 303-857-2711
  • Fax: 303-857-1408

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number27735
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: