Provider Demographics
NPI:1659446698
Name:MACKALL, JULIE ANN (OD)
Entity Type:Individual
Prefix:
First Name:JULIE
Middle Name:ANN
Last Name:MACKALL
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:JULIE
Other - Middle Name:ANN
Other - Last Name:OLINGER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2400 SOUTHEAST BLVD STE A
Mailing Address - Street 2:
Mailing Address - City:SALEM
Mailing Address - State:OH
Mailing Address - Zip Code:44460-3482
Mailing Address - Country:US
Mailing Address - Phone:330-332-4501
Mailing Address - Fax:330-332-4540
Practice Address - Street 1:2400 SOUTHEAST BLVD
Practice Address - Street 2:SUITE A
Practice Address - City:SALEM
Practice Address - State:OH
Practice Address - Zip Code:44460
Practice Address - Country:US
Practice Address - Phone:330-332-4501
Practice Address - Fax:330-332-4540
Is Sole Proprietor?:No
Enumeration Date:2006-11-22
Last Update Date:2015-01-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH5492152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH000000350487OtherANTHEM
OH4150721Medicare PIN
OH000000350487OtherANTHEM
OHJU9350611Medicare ID - Type Unspecified