Basic Information
| Provider Information | |||||||||
| NPI: | 1588823421 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | DEPAN | ||||||||
| FirstName: | CORMAC | ||||||||
| MiddleName: | DERMITT | ||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 123 SUMMER ST | ||||||||
| Address2: | |||||||||
| City: | WORCESTER | ||||||||
| State: | MA | ||||||||
| PostalCode: | 016081216 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5083683103 | ||||||||
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| Practice Location | |||||||||
| Address1: | 123 SUMMER ST | ||||||||
| Address2: | |||||||||
| City: | WORCESTER | ||||||||
| State: | MA | ||||||||
| PostalCode: | 016081216 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5083683103 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/05/2008 | ||||||||
| LastUpdateDate: | 07/06/2011 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207YX0905X | 246127 | MA | Y | Allopathic & Osteopathic Physicians | Otolaryngology | Otolaryngology/Facial Plastic Surgery | 390200000X | N | Student, Health Care | Student in an Organized Health Care Education/Training Program |
No ID Information.