Healthcare Provider Details

I. General information

NPI: 1245619105
Provider Name (Legal Business Name): ANNA MACKIN M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/26/2015
Last Update Date: 06/16/2021
Certification Date: 06/16/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1819 ELECTRIC RD STE 1B
ROANOKE VA
24018-1605
US

IV. Provider business mailing address

1819 ELECTRIC RD STE 1B
ROANOKE VA
24018-1605
US

V. Phone/Fax

Practice location:
  • Phone: 540-855-5120
  • Fax: 540-342-4373
Mailing address:
  • Phone: 540-855-5120
  • Fax: 540-342-4373

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207W00000X
TaxonomyOphthalmology Physician
License NumberTL.0006375
License Number StateCO
# 2
Primary TaxonomyN
Taxonomy Code207WX0107X
TaxonomyRetina Specialist (Ophthalmology) Physician
License Number036.149405
License Number StateIL
# 3
Primary TaxonomyY
Taxonomy Code207WX0107X
TaxonomyRetina Specialist (Ophthalmology) Physician
License Number0101271654
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: