Provider Demographics
NPI:1063578854
Name:SNEBOLD, MACKIE A (DO)
Entity type:Individual
Prefix:
First Name:MACKIE
Middle Name:A
Last Name:SNEBOLD
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:MACKIE
Other - Middle Name:A
Other - Last Name:KOKKELENBURG
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:3920 N JOHNSBURG RD
Mailing Address - Street 2:
Mailing Address - City:JOHNSBURG
Mailing Address - State:IL
Mailing Address - Zip Code:60051-6320
Mailing Address - Country:US
Mailing Address - Phone:815-344-0088
Mailing Address - Fax:815-363-3477
Practice Address - Street 1:3920 N JOHNSBURG RD
Practice Address - Street 2:
Practice Address - City:JOHNSBURG
Practice Address - State:IL
Practice Address - Zip Code:60051-6320
Practice Address - Country:US
Practice Address - Phone:815-344-0088
Practice Address - Fax:815-363-3477
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-28
Last Update Date:2020-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036067812207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL0360678124Medicaid
IL05615148OtherBCBS
IL05615148OtherBCBS
IL719860-C42544Medicare PIN