Provider Demographics
NPI:1417029992
Name:MACKIE, LORA E (MD)
Entity Type:Individual
Prefix:DR
First Name:LORA
Middle Name:E
Last Name:MACKIE
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 1:2101 E JEFFERSON ST
Mailing Address - Street 2:KAISER PERMANENTE MEDICARE ENROLLMENT
Mailing Address - City:ROCKVILLE
Mailing Address - State:MD
Mailing Address - Zip Code:20852-4908
Mailing Address - Country:US
Mailing Address - Phone:301-816-2424
Mailing Address - Fax:
Practice Address - Street 1:43480 YUKON DR STE 100
Practice Address - Street 2:
Practice Address - City:ASHBURN
Practice Address - State:VA
Practice Address - Zip Code:20147-6988
Practice Address - Country:US
Practice Address - Phone:571-252-6000
Practice Address - Fax:571-252-6011
Is Sole Proprietor?:No
Enumeration Date:2006-11-14
Last Update Date:2011-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101042024207Q00000X
MDD0071901207Q00000X
DCMD039753207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
E13424Medicare UPIN
007833M92Medicare ID - Type Unspecified