Provider Demographics
NPI:1447364872
Name:MCDERMOTT, PATRICIA (MD)
Entity type:Individual
Prefix:
First Name:PATRICIA
Middle Name:
Last Name:MCDERMOTT
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5767 W CENTURY BLVD STE 400
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90045-5631
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:23815 STUART RANCH RD STE 300
Practice Address - Street 2:
Practice Address - City:MALIBU
Practice Address - State:CA
Practice Address - Zip Code:90265
Practice Address - Country:US
Practice Address - Phone:310-456-1668
Practice Address - Fax:310-456-8838
Is Sole Proprietor?:No
Enumeration Date:2006-08-19
Last Update Date:2019-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG45516207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G455160Medicaid
A50072Medicare UPIN
CABB809WMedicare PIN
WG45516HMedicare ID - Type UnspecifiedMEDICARE PART B PPIN