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NPI Code Detail

MEDICARE: DR. MARK T MCDERMOTT OD

MEDICARE: DR. MARK T MCDERMOTT OD
Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

# Taxonomy Code Taxonomy License Number License Number State
1152W00000XOptometrist02169IA
2152W00000XOptometrist2594MN

Other Identifiers

# Provider Identifier Provider Identifier Type Provider Identifier State Provider Identifier Issuer
122 07646OTHERMNMEDICA
2124899OTHERMNU CARE
3615152747OTHERMNMETROPOLITAN HEALTH PLAN
4MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
526613OTHERMNHEALTH PARTNERS
657D32MCOTHERMNBLUE CROSS BLUE SHIELD

General Provider Information

NPI Number : 1083680599
Entity Type Code : Individual
Provider Name (Legal Business Name) : DR. MARK T MCDERMOTT OD
Provider Business Mailing Address
First Line : 4243 4TH AVE S
Second Line :
City : MINNEAPOLIS
State : MN
Zip : 55409-2113
Country : US
Telephone Number : 612-821-2003
Fax Number : 612-821-2818
Provider Business Practice Location Address
First Line : 4243 4TH AVE S
Second Line :
City : MINNEAPOLIS
State : MN
Zip : 55409-2113
Country : US
Telephone Number : 612-821-2003
Fax Number : 612-821-2818
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 02/24/2006
Last Update Date : 06/16/2025

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Directions to “ DR. MARK T MCDERMOTT OD” Practice Location

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