Provider Demographics
NPI:1437140126
Name:MACKIE, CHRISTINE M (MD)
Entity Type:Individual
Prefix:
First Name:CHRISTINE
Middle Name:M
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 1:4304 DEL PRADO BLVD S
Mailing Address - Street 2:
Mailing Address - City:CAPE CORAL
Mailing Address - State:FL
Mailing Address - Zip Code:33904-7169
Mailing Address - Country:US
Mailing Address - Phone:239-540-0800
Mailing Address - Fax:239-540-0806
Practice Address - Street 1:4304 DEL PRADO BLVD S
Practice Address - Street 2:
Practice Address - City:CAPE CORAL
Practice Address - State:FL
Practice Address - Zip Code:33904-7169
Practice Address - Country:US
Practice Address - Phone:239-540-0800
Practice Address - Fax:239-540-0806
Is Sole Proprietor?:Yes
Enumeration Date:2005-11-02
Last Update Date:2020-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME94225207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL29322OtherBC/BS
FLP00379350OtherRAILROAD MEDICARE PIN
FL273771000Medicaid
FLCC4198OtherRAILROAD MEDICARE GROUP #
FL273771000Medicaid
FLI03645Medicare UPIN