Provider Demographics
NPI:1295982668
Name:MACKEY, RYAN THOMAS (DPM)
Entity type:Individual
Prefix:DR
First Name:RYAN
Middle Name:THOMAS
Last Name:MACKEY
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1001 W MAIN ST
Mailing Address - Street 2:
Mailing Address - City:WAUPUN
Mailing Address - State:WI
Mailing Address - Zip Code:53963-1601
Mailing Address - Country:US
Mailing Address - Phone:920-324-9301
Mailing Address - Fax:920-324-9473
Practice Address - Street 1:1001 W MAIN ST
Practice Address - Street 2:
Practice Address - City:WAUPUN
Practice Address - State:WI
Practice Address - Zip Code:53963-1601
Practice Address - Country:US
Practice Address - Phone:920-361-3063
Practice Address - Fax:920-361-7317
Is Sole Proprietor?:Yes
Enumeration Date:2008-08-27
Last Update Date:2016-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COPOD-0000708213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
COP01735659OtherRAILROAD MEDICARE
TX305219302Medicaid
TXP01736047OtherRAILROAD MEDICARE
TX536194YR1KMedicare PIN
TXP01736047OtherRAILROAD MEDICARE