Provider Demographics
NPI:1639412463
Name:MACKRIDES, NICHOLAS (MD)
Entity Type:Individual
Prefix:DR
First Name:NICHOLAS
Middle Name:
Last Name:MACKRIDES
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3500 N BROAD ST # 1A
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19140-4106
Mailing Address - Country:US
Mailing Address - Phone:215-728-3675
Mailing Address - Fax:215-728-2848
Practice Address - Street 1:333 COTTMAN AVE
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19111
Practice Address - Country:US
Practice Address - Phone:215-728-3675
Practice Address - Fax:215-728-2848
Is Sole Proprietor?:No
Enumeration Date:2013-03-29
Last Update Date:2022-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD460234207ZP0102X, 207ZP0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ZP0102XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology & Clinical Pathology