1891147658 NPI number — ANDREW MICHAEL MACKELPRANG O.D.

Table of content: ANDREW MICHAEL MACKELPRANG O.D. (NPI 1891147658)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1891147658 NPI number — ANDREW MICHAEL MACKELPRANG O.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MACKELPRANG
Provider First Name:
ANDREW
Provider Middle Name:
MICHAEL
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
O.D.
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1891147658
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/11/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
220 N MCKEMY AVE
Provider Second Line Business Mailing Address:
APT 10102
Provider Business Mailing Address City Name:
CHANDLER
Provider Business Mailing Address State Name:
AZ
Provider Business Mailing Address Postal Code:
85226-2654
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
480-835-4472
Provider Business Mailing Address Fax Number:
480-893-8172

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4386 N ORACLE RD
Provider Second Line Business Practice Location Address:
# 100
Provider Business Practice Location Address City Name:
TUCSON
Provider Business Practice Location Address State Name:
AZ
Provider Business Practice Location Address Postal Code:
85705-1656
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
520-887-4435
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
07/05/2016

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 152W00000X , with the licence number:  2130 , registered in the state of AZ ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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