Healthcare Provider Details

I. General information

NPI: 1326085820
Provider Name (Legal Business Name): MARK LEO MCDERMOTT MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/01/2006
Last Update Date: 05/18/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

KRESGE EYE INSTITUTE 4717 ST ANTOINE
DETROIT MI
48201
US

IV. Provider business mailing address

1560 EAST MAPLE ROAD SUITE 400-CREDENTIALING
TROY MI
48083-1189
US

V. Phone/Fax

Practice location:
  • Phone: 313-577-8900
  • Fax: 313-577-0700
Mailing address:
  • Phone: 248-581-5976
  • Fax: 248-581-5640

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207W00000X
TaxonomyOphthalmology Physician
License Number4301054291
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: