MEDICARE: ANNETTE M ST PIERRE MACKOUL MD PA

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
1	208000000X	Pediatrics Physician	ME67399	FL

Other Identifiers

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

General Provider Information

NPI Number	:	1659679561
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	ANNETTE M ST PIERRE MACKOUL MD PA

Provider Business Mailing Address
First Line	:	8530 GRANITE CT
Second Line	:
City	:	FORT MYERS
State	:	FL
Zip	:	33908-4102
Country	:	US
Telephone Number	:	239-415-1131
Fax Number	:	239-415-1136

Provider Business Practice Location Address
First Line	:	8530 GRANITE CT
Second Line	:
City	:	FORT MYERS
State	:	FL
Zip	:	33908-4102
Country	:	US
Telephone Number	:	239-415-1131
Fax Number	:	239-415-1136

Authorized Official
Title or Position	:	OFFICE MANAGER
Name	:	LISET FLEITAS
Credential	:
Telephone Number	:	239-415-1131

Provider Enumeration Date	:	03/02/2011
Last Update Date	:	05/28/2020

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Practice Location Address:

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Directions to “ANNETTE M ST PIERRE MACKOUL MD PA ” Practice Location

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