Provider Demographics
NPI:1972595833
Name:MACKIE, ROBERT W (MD)
Entity Type:Individual
Prefix:
First Name:ROBERT
Middle Name:W
Last Name:MACKIE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:1160 E 3900 S
Mailing Address - Street 2:STE 2000
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84124-1202
Mailing Address - Country:US
Mailing Address - Phone:801-266-3418
Mailing Address - Fax:801-288-4444
Practice Address - Street 1:1160 E 3900 S
Practice Address - Street 2:STE 2000
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84124-1202
Practice Address - Country:US
Practice Address - Phone:801-266-3418
Practice Address - Fax:801-288-4444
Is Sole Proprietor?:No
Enumeration Date:2005-08-17
Last Update Date:2012-10-30
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
UT159430-1205207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT05365Medicaid
E00015Medicare UPIN
UT05365Medicaid