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General NPI Number Information
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NPI Number | 1083680599
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Entity Type | Individual
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Provider Name | MARK T MCDERMOTT OD
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Gender | Male
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Dates
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Enumeration Date | 02/24/2006
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Last Update Date | 06/16/2025
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Provider Practice Location Address
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Address Line | 4243 4TH AVE S
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City | MINNEAPOLIS
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State | MN
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Zip | 55409-2113
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Country | US
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Telephone | 612-821-2003
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Fax | 612-821-2818
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Provider Business Mailing Address
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Address Line | 4243 4TH AVE S
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City | MINNEAPOLIS
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State | MN
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Zip | 55409-2113
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Country | US
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Telephone | 612-821-2003
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Fax | 612-821-2818
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 152W00000X
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Taxonomy Name | Optometrist
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License Number | 02169
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License Number State | IA
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Taxonomy #2
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Taxonomy Code | 152W00000X
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Taxonomy Name | Optometrist
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License Number | 2594
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License Number State | MN
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