Provider Demographics
NPI:1457352437
Name:MCDERMOTT, DERMOT M (PA-C)
Entity type:Individual
Prefix:
First Name:DERMOT
Middle Name:M
Last Name:MCDERMOTT
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:874 HOWARD AVE
Mailing Address - Street 2:
Mailing Address - City:NEW HAVEN
Mailing Address - State:CT
Mailing Address - Zip Code:06519-1106
Mailing Address - Country:US
Mailing Address - Phone:203-688-8200
Mailing Address - Fax:203-688-8204
Practice Address - Street 1:874 HOWARD AVE
Practice Address - Street 2:
Practice Address - City:NEW HAVEN
Practice Address - State:CT
Practice Address - Zip Code:06519-1106
Practice Address - Country:US
Practice Address - Phone:203-688-8200
Practice Address - Fax:203-688-8204
Is Sole Proprietor?:No
Enumeration Date:2005-08-02
Last Update Date:2009-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT000997363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT000997OtherCONNECTICARE
CT290000997CT01OtherANTHEM BC/BS
CTP2531898OtherOXFORD
CT0Q2937OtherHELATH NET
CT061561581OtherUNITED HEALTHCARE
CT970019423OtherRAIL ROAD MEDICARE
CT369530OtherWELLCARE OF CT
CT369530OtherWELLCARE OF CT
CT970019423OtherRAIL ROAD MEDICARE