Provider Demographics
NPI:1356214258
Name:PHILEUS, MACKINSON
Entity type:Individual
Prefix:
First Name:MACKINSON
Middle Name:
Last Name:PHILEUS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:BIG
Other - Middle Name:
Other - Last Name:MAC
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:3947 ISLAND CLUB CIR W
Mailing Address - Street 2:
Mailing Address - City:LAKE WORTH
Mailing Address - State:FL
Mailing Address - Zip Code:33462-2183
Mailing Address - Country:US
Mailing Address - Phone:561-895-3780
Mailing Address - Fax:
Practice Address - Street 1:714 BARNETT DR BAY 23
Practice Address - Street 2:
Practice Address - City:LAKE WORTH BEACH
Practice Address - State:FL
Practice Address - Zip Code:33461-3357
Practice Address - Country:US
Practice Address - Phone:561-895-3780
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-09-26
Last Update Date:2025-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL171W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes171W00000XOther Service ProvidersContractorGroup - Single Specialty