Provider Demographics
NPI:1669765095
Name:MACKE, JEREMY JAMES (MD)
Entity type:Individual
Prefix:
First Name:JEREMY
Middle Name:JAMES
Last Name:MACKE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3707 NEW VISION DR
Mailing Address - Street 2:
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46845-1702
Mailing Address - Country:US
Mailing Address - Phone:260-471-9466
Mailing Address - Fax:
Practice Address - Street 1:2423 SCOTS PINE XING
Practice Address - Street 2:
Practice Address - City:DURHAM
Practice Address - State:NC
Practice Address - Zip Code:27713-6221
Practice Address - Country:US
Practice Address - Phone:321-558-4576
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-05-18
Last Update Date:2017-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC2015-020462085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology