Provider Demographics
NPI:1972595643
Name:MACKIE, MICHAEL A (OD)
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:A
Last Name:MACKIE
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2003 CORTEZ RD W
Mailing Address - Street 2:
Mailing Address - City:BRADENTON
Mailing Address - State:FL
Mailing Address - Zip Code:34207-1241
Mailing Address - Country:US
Mailing Address - Phone:941-756-2020
Mailing Address - Fax:941-756-4486
Practice Address - Street 1:2003 CORTEZ RD W
Practice Address - Street 2:
Practice Address - City:BRADENTON
Practice Address - State:FL
Practice Address - Zip Code:34207-1241
Practice Address - Country:US
Practice Address - Phone:941-756-2020
Practice Address - Fax:941-756-4486
Is Sole Proprietor?:Yes
Enumeration Date:2005-08-18
Last Update Date:2016-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOPC3022152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL20737ZOtherINDIVIDUAL MEDICARE ID
FL620192000Medicaid
FLU63877Medicare UPIN
FL20737ZMedicare ID - Type Unspecified