MEDICARE: THOMAS DAVID MARCOTTE PH.D.

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
1	103G00000X	Clinical Neuropsychologist	15428	CA

General Provider Information

NPI Number	:	1851781942
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	THOMAS DAVID MARCOTTE PH.D.

Provider Business Mailing Address
First Line	:	PO BOX 19088
Second Line	:
City	:	SAN DIEGO
State	:	CA
Zip	:	92159-0088
Country	:	US
Telephone Number	:	619-543-5044
Fax Number	:

Provider Business Practice Location Address
First Line	:	220 DICKINSON ST
Second Line	:	SUITE B
City	:	SAN DIEGO
State	:	CA
Zip	:	92103-2071
Country	:	US
Telephone Number	:	619-543-5044
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	01/28/2015
Last Update Date	:	01/28/2015

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