Provider Demographics
NPI:1255902193
Name:MCDERMOTT, THOMAS M (PTA)
Entity type:Individual
Prefix:
First Name:THOMAS
Middle Name:M
Last Name:MCDERMOTT
Suffix:
Gender:M
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2533 BLOSSOM LAKE DR
Mailing Address - Street 2:
Mailing Address - City:HOLIDAY
Mailing Address - State:FL
Mailing Address - Zip Code:34691-6769
Mailing Address - Country:US
Mailing Address - Phone:727-967-0404
Mailing Address - Fax:
Practice Address - Street 1:7210 BEACON WOODS DR
Practice Address - Street 2:
Practice Address - City:HUDSON
Practice Address - State:FL
Practice Address - Zip Code:34667-1974
Practice Address - Country:US
Practice Address - Phone:727-863-1521
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-07-01
Last Update Date:2021-07-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL10701208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLM236833640470Medicaid