Provider Demographics
NPI:1871710285
Name:MCDERMOTT, NICOLE B (M D)
Entity type:Individual
Prefix:
First Name:NICOLE
Middle Name:B
Last Name:MCDERMOTT
Suffix:
Gender:F
Credentials:M D
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 203
Mailing Address - Street 2:
Mailing Address - City:GLENWOOD SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:81602-0203
Mailing Address - Country:US
Mailing Address - Phone:303-906-4078
Mailing Address - Fax:
Practice Address - Street 1:1906 BLAKE AVENUE
Practice Address - Street 2:
Practice Address - City:GLENWOOD SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:81601
Practice Address - Country:US
Practice Address - Phone:970-945-6535
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-04-19
Last Update Date:2008-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO44410207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO20086776Medicaid
017283OtherKAISER-COMMERCIAL NUMBER
CO811861Medicare PIN