Provider Demographics
NPI:1659679561
Name:ANNETTE M ST PIERRE MACKOUL MD PA
Entity type:Organization
Organization Name:ANNETTE M ST PIERRE MACKOUL MD PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:LISET
Authorized Official - Middle Name:
Authorized Official - Last Name:FLEITAS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:239-415-1131
Mailing Address - Street 1:8530 GRANITE CT
Mailing Address - Street 2:
Mailing Address - City:FORT MYERS
Mailing Address - State:FL
Mailing Address - Zip Code:33908-4102
Mailing Address - Country:US
Mailing Address - Phone:239-415-1131
Mailing Address - Fax:239-415-1136
Practice Address - Street 1:8530 GRANITE CT
Practice Address - Street 2:
Practice Address - City:FORT MYERS
Practice Address - State:FL
Practice Address - Zip Code:33908-4102
Practice Address - Country:US
Practice Address - Phone:239-415-1131
Practice Address - Fax:239-415-1136
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-03-02
Last Update Date:2020-05-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME67399208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL000697700Medicaid
FL377085100Medicaid
FL003463600Medicaid
FL024174700Medicaid