Provider Demographics
NPI:1871582056
Name:MACKOUL, DAVID A (MD)
Entity type:Individual
Prefix:
First Name:DAVID
Middle Name:A
Last Name:MACKOUL
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 1:206 SE 16TH PL
Mailing Address - Street 2:
Mailing Address - City:CAPE CORAL
Mailing Address - State:FL
Mailing Address - Zip Code:33990
Mailing Address - Country:US
Mailing Address - Phone:239-573-2001
Mailing Address - Fax:239-573-2006
Practice Address - Street 1:206 SE 16TH PL
Practice Address - Street 2:
Practice Address - City:CAPE CORAL
Practice Address - State:FL
Practice Address - Zip Code:33990
Practice Address - Country:US
Practice Address - Phone:239-573-2001
Practice Address - Fax:239-573-2006
Is Sole Proprietor?:No
Enumeration Date:2005-10-19
Last Update Date:2010-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME67400173000000X, 208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
No173000000XOther Service ProvidersLegal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL258711400Medicaid
FL258711402Medicaid
FL377086900Medicaid
FL377086900Medicaid
FL258711400Medicaid