Provider Demographics
NPI:1326044108
Name:MACKMAN, GARY (MD)
Entity Type:Individual
Prefix:DR
First Name:GARY
Middle Name:
Last Name:MACKMAN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:GARY
Other - Middle Name:
Other - Last Name:MACKMAN
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:1130 E MISSOURI AVE
Mailing Address - Street 2:STE 100
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85014-2718
Mailing Address - Country:US
Mailing Address - Phone:602-995-1166
Mailing Address - Fax:602-995-2390
Practice Address - Street 1:1130 E MISSOURI AVE
Practice Address - Street 2:STE 100
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85014-2718
Practice Address - Country:US
Practice Address - Phone:602-995-1166
Practice Address - Fax:602-995-2390
Is Sole Proprietor?:Yes
Enumeration Date:2005-06-25
Last Update Date:2012-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ12411207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ860220938OtherTAX ID
AZC99912Medicare UPIN
AZZ152370Medicare PIN