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NPI Code Detail

MEDICARE: DR. CHARLES W MACKETT III MD

MEDICARE: DR. CHARLES W MACKETT III MD
Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

# Taxonomy Code Taxonomy License Number License Number State
1174400000XSpecialistMD425999PA
2207Q00000XFamily Medicine PhysicianME107676FL

Other Identifiers

# Provider Identifier Provider Identifier Type Provider Identifier State Provider Identifier Issuer
1MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2ME107676OTHERFLMEDICAL LICENSE
3MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number : 1366416232
Entity Type Code : Individual
Provider Name (Legal Business Name) : DR. CHARLES W MACKETT III MD
Provider Business Mailing Address
First Line : 1555 INDIAN RIVER BLVD STE B210
Second Line :
City : VERO BEACH
State : FL
Zip : 32960-7113
Country : US
Telephone Number : 772-257-8224
Fax Number : 772-252-3245
Provider Business Practice Location Address
First Line : 1400 27TH ST
Second Line :
City : VERO BEACH
State : FL
Zip : 32960-0303
Country : US
Telephone Number : 772-257-8224
Fax Number : 772-252-3245
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 02/15/2006
Last Update Date : 02/12/2025

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Directions to “ DR. CHARLES W MACKETT III MD” Practice Location

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