Provider Demographics
NPI:1871738898
Name:JULIE A. MACKALL OD LLC
Entity type:Organization
Organization Name:JULIE A. MACKALL OD LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DOCTOR
Authorized Official - Prefix:
Authorized Official - First Name:JULIE
Authorized Official - Middle Name:A
Authorized Official - Last Name:MACKALL
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:330-332-4501
Mailing Address - Street 1:2400 SOUTHEAST BLVD STE A
Mailing Address - Street 2:
Mailing Address - City:SALEM
Mailing Address - State:OH
Mailing Address - Zip Code:44460-3482
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2400 SOUTHEAST BLVD STE A
Practice Address - Street 2:
Practice Address - City:SALEM
Practice Address - State:OH
Practice Address - Zip Code:44460-3482
Practice Address - Country:US
Practice Address - Phone:330-332-4501
Practice Address - Fax:330-332-4540
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-12-04
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH5492T2404152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2803210Medicaid
OH6380000001Medicare NSC
OH9350611Medicare PIN