1245333756 NPI number — DR. JOHN M DEMARCO DDS

Table of content: DR. JOHN M DEMARCO DDS (NPI 1245333756)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1245333756 NPI number — DR. JOHN M DEMARCO DDS

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
DEMARCO
Provider First Name:
JOHN
Provider Middle Name:
M
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
DDS
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
DEMARCO DDS INC
Provider Other First Name:
JOHN
Provider Other Middle Name:
M.
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
DDS
Provider Other Last Name Type Code:
2

NPI Number Information

NPI Number:
1245333756
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/26/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 1357
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
FORT MYERS
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
33902-1357
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
740-296-4965
Provider Business Mailing Address Fax Number:
239-278-3857

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4300 KINGS HWY
Provider Second Line Business Practice Location Address:
#500
Provider Business Practice Location Address City Name:
PORT CHARLOTTE
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
33980-2917
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
239-344-2337
Provider Business Practice Location Address Fax Number:
941-629-2365
Provider Enumeration Date:
09/07/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 1223G0001X , with the licence number:  30014059 , registered in the state of OH ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 1223G0001X , with the licence number: HAD46 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 005587200 , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".
  • Identifier: 0248637 , issued by the state of ( OH ) . This identifiers is of the category "MEDICAID".




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