Provider Demographics
NPI:1124174453
Name:MACKELL, PAUL EDWARD (MD)
Entity type:Individual
Prefix:
First Name:PAUL
Middle Name:EDWARD
Last Name:MACKELL
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 1:4269 CARTER TRL
Mailing Address - Street 2:
Mailing Address - City:BOULDER
Mailing Address - State:CO
Mailing Address - Zip Code:80301-3805
Mailing Address - Country:US
Mailing Address - Phone:303-666-4606
Mailing Address - Fax:
Practice Address - Street 1:588 US HIGHWAY 287
Practice Address - Street 2:SUITE 204
Practice Address - City:LAFAYETTE
Practice Address - State:CO
Practice Address - Zip Code:80026-2604
Practice Address - Country:US
Practice Address - Phone:303-666-4606
Practice Address - Fax:303-666-4610
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-27
Last Update Date:2010-12-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO25320207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO01253202Medicaid
CO1639358518OtherCORPORATION NPI
COC550358Medicare PIN
CO1639358518OtherCORPORATION NPI