Provider Demographics
NPI:1306949581
Name:MACKEL, SUSAN ELIZABETH (MD)
Entity type:Individual
Prefix:MRS
First Name:SUSAN
Middle Name:ELIZABETH
Last Name:MACKEL
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:895 MIDDLE GROUND BLVD.
Mailing Address - Street 2:SUITE 302
Mailing Address - City:NEWPORT NEWS
Mailing Address - State:VA
Mailing Address - Zip Code:23606-4250
Mailing Address - Country:US
Mailing Address - Phone:757-873-0161
Mailing Address - Fax:757-873-0205
Practice Address - Street 1:895 MIDDLE GROUND BLVD.
Practice Address - Street 2:SUITE 302
Practice Address - City:NEWPORT NEWS
Practice Address - State:VA
Practice Address - Zip Code:23606-4250
Practice Address - Country:US
Practice Address - Phone:757-873-0161
Practice Address - Fax:757-873-0205
Is Sole Proprietor?:No
Enumeration Date:2006-09-06
Last Update Date:2010-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101032520207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA5963303Medicaid
B07582Medicare UPIN
VA5963303Medicaid