Provider Demographics
NPI:1891799821
Name:MACKEY, BRUCE A (MD)
Entity Type:Individual
Prefix:
First Name:BRUCE
Middle Name:A
Last Name:MACKEY
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 1:3957 E COVELL RD
Mailing Address - Street 2:
Mailing Address - City:EDMOND
Mailing Address - State:OK
Mailing Address - Zip Code:73034-6909
Mailing Address - Country:US
Mailing Address - Phone:405-285-7246
Mailing Address - Fax:405-285-7546
Practice Address - Street 1:3957 E COVELL RD
Practice Address - Street 2:
Practice Address - City:EDMOND
Practice Address - State:OK
Practice Address - Zip Code:73034-6909
Practice Address - Country:US
Practice Address - Phone:405-285-7246
Practice Address - Fax:405-285-7546
Is Sole Proprietor?:No
Enumeration Date:2005-06-08
Last Update Date:2013-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK16205208VP0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208VP0000XAllopathic & Osteopathic PhysiciansPain MedicinePain Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
249722602Medicare PIN
D34970Medicare UPIN