Provider Demographics
NPI:1366533978
Name:MCDERMOTT, JOHN J III (MD)
Entity type:Individual
Prefix:
First Name:JOHN
Middle Name:J
Last Name:MCDERMOTT
Suffix:III
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:JOHN
Other - Middle Name:J
Other - Last Name:MCDERMOTT
Other - Suffix:III
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:655 E FOOTHILL BLVD
Mailing Address - Street 2:
Mailing Address - City:CLAREMONT
Mailing Address - State:CA
Mailing Address - Zip Code:91711-3511
Mailing Address - Country:US
Mailing Address - Phone:909-624-8077
Mailing Address - Fax:909-624-1467
Practice Address - Street 1:655 E FOOTHILL BLVD
Practice Address - Street 2:
Practice Address - City:CLAREMONT
Practice Address - State:CA
Practice Address - Zip Code:91711-3511
Practice Address - Country:US
Practice Address - Phone:909-624-8077
Practice Address - Fax:909-624-1467
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-27
Last Update Date:2012-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA62498207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A624980Medicaid
CAA62498OtherSTATE LIC #
CAE CROSS PINOtherBLUE CROSS PIN
CAA62498OtherSTATE LIC #