Provider Demographics
NPI:1114999000
Name:MACKOOL, BONNIE TERESA (MD)
Entity Type:Individual
Prefix:DR
First Name:BONNIE
Middle Name:TERESA
Last Name:MACKOOL
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:PO BOX 9142
Mailing Address - Street 2:
Mailing Address - City:CHARLESTOWN
Mailing Address - State:MA
Mailing Address - Zip Code:02129-9142
Mailing Address - Country:US
Mailing Address - Phone:617-724-0287
Mailing Address - Fax:617-726-2894
Practice Address - Street 1:50 STANIFORD ST
Practice Address - Street 2:SUITE 200
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02114-2517
Practice Address - Country:US
Practice Address - Phone:617-726-2914
Practice Address - Fax:617-724-2135
Is Sole Proprietor?:No
Enumeration Date:2006-02-03
Last Update Date:2012-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA76647207N00000X
CAG81270207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA3107621Medicaid
MAJ13548OtherBCBS MA
MA729619OtherTUFTS HEALTH PLAN
MAJ13548OtherBCBS MA
F53825Medicare UPIN