Healthcare Provider Details

I. General information

NPI: 1871582056
Provider Name (Legal Business Name): DAVID A MACKOUL MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/19/2005
Last Update Date: 11/08/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

206 SE 16TH PL
CAPE CORAL FL
33990
US

IV. Provider business mailing address

206 SE 16TH PL
CAPE CORAL FL
33990
US

V. Phone/Fax

Practice location:
  • Phone: 239-573-2001
  • Fax: 239-573-2006
Mailing address:
  • Phone: 239-573-2001
  • Fax: 239-573-2006

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code173000000X
TaxonomyLegal Medicine
License NumberME67400
License Number StateFL
# 2
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberME67400
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: