Healthcare Provider Details

I. General information

NPI: 1114434032
Provider Name (Legal Business Name): DAVID JOHN MCDERMOTT ATC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/30/2017
Last Update Date: 04/26/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

BLDG. H1 JULIAN C SMITH RD.,
CAMP LEJUENE NC
28547
US

IV. Provider business mailing address

19 ST JOSEPH ST APT 102
FORT KENT ME
04743-1172
US

V. Phone/Fax

Practice location:
  • Phone: 207-316-7134
  • Fax:
Mailing address:
  • Phone: 207-316-7134
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License NumberAT623
License Number StateME

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: