Provider Demographics
NPI:1972585909
Name:MACKIE, DIANE M (DO)
Entity type:Individual
Prefix:DR
First Name:DIANE
Middle Name:M
Last Name:MACKIE
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5620 SOUTHWYCK BLVD
Mailing Address - Street 2:
Mailing Address - City:TOLEDO
Mailing Address - State:OH
Mailing Address - Zip Code:43614-1501
Mailing Address - Country:US
Mailing Address - Phone:800-288-8325
Mailing Address - Fax:
Practice Address - Street 1:1020 HIGH RD
Practice Address - Street 2:
Practice Address - City:BREMEN
Practice Address - State:IN
Practice Address - Zip Code:46506-0008
Practice Address - Country:US
Practice Address - Phone:574-546-2211
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-11-16
Last Update Date:2010-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN02000864A207ZP0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ZP0102XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology & Clinical Pathology
Provider Identifiers
StateIdentifier IDID TypeIssuer
INE45893Medicare UPIN
IN188300Medicare PIN