Provider Demographics
NPI:1083680599
Name:MCDERMOTT, MARK T (OD)
Entity type:Individual
Prefix:DR
First Name:MARK
Middle Name:T
Last Name:MCDERMOTT
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4243 4TH AVE S
Mailing Address - Street 2:
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55409-2113
Mailing Address - Country:US
Mailing Address - Phone:612-821-2003
Mailing Address - Fax:612-821-2818
Practice Address - Street 1:4243 4TH AVE S
Practice Address - Street 2:
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55409-2113
Practice Address - Country:US
Practice Address - Phone:612-821-2003
Practice Address - Fax:612-821-2818
Is Sole Proprietor?:No
Enumeration Date:2006-02-24
Last Update Date:2025-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA02169152W00000X
MN2594152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN22 07646OtherMEDICA
MN124899OtherU CARE
MN615152747OtherMETROPOLITAN HEALTH PLAN
MN152713400Medicaid
MN26613OtherHEALTH PARTNERS
MN57D32MCOtherBLUE CROSS BLUE SHIELD
06426800001Medicare NSC
MN22 07646OtherMEDICA
410001052Medicare ID - Type Unspecified
410037349Medicare ID - Type UnspecifiedRAILROAD MEDICARE