Provider Demographics
NPI:1124080585
Name:MACKRELL, PETER J (MD)
Entity type:Individual
Prefix:DR
First Name:PETER
Middle Name:J
Last Name:MACKRELL
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:520 UPPER CHESAPEAKE DR
Mailing Address - Street 2:SUITE 306
Mailing Address - City:BEL AIR
Mailing Address - State:MD
Mailing Address - Zip Code:21014-4339
Mailing Address - Country:US
Mailing Address - Phone:410-879-2006
Mailing Address - Fax:410-879-0248
Practice Address - Street 1:520 UPPER CHESAPEAKE DR
Practice Address - Street 2:SUITE 306
Practice Address - City:BEL AIR
Practice Address - State:MD
Practice Address - Zip Code:21014-4339
Practice Address - Country:US
Practice Address - Phone:410-879-2006
Practice Address - Fax:410-879-0248
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-04-03
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD602822086S0129X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2086S0129XAllopathic & Osteopathic PhysiciansSurgeryVascular Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
MDBM7401196OtherDEA
MDH91497Medicare UPIN
MDBM7401196OtherDEA