Provider Demographics
NPI:1659389948
Name:DAVID A MACKOUL, M.D., P.A.
Entity Type:Organization
Organization Name:DAVID A MACKOUL, M.D., P.A.
Other - Org Name:MACKOUL PEDIATRICS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:
Authorized Official - Last Name:MACKOUL
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:239-573-2001
Mailing Address - Street 1:206 SE 16TH PL
Mailing Address - Street 2:
Mailing Address - City:CAPE CORAL
Mailing Address - State:FL
Mailing Address - Zip Code:33990-1329
Mailing Address - Country:US
Mailing Address - Phone:239-829-1747
Mailing Address - Fax:239-573-2006
Practice Address - Street 1:206 SE 16TH PL
Practice Address - Street 2:
Practice Address - City:CAPE CORAL
Practice Address - State:FL
Practice Address - Zip Code:33990-1329
Practice Address - Country:US
Practice Address - Phone:239-829-1747
Practice Address - Fax:239-573-2006
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-03
Last Update Date:2010-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL258711402Medicaid
FL258711400Medicaid