Provider Demographics
NPI:1174535470
Name:MACKIEL, PUNNOOSE (MD)
Entity type:Individual
Prefix:DR
First Name:PUNNOOSE
Middle Name:
Last Name:MACKIEL
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 1:1240 RIDGE RD
Mailing Address - Street 2:
Mailing Address - City:WAUKESHA
Mailing Address - State:WI
Mailing Address - Zip Code:53186-1425
Mailing Address - Country:US
Mailing Address - Phone:262-574-9342
Mailing Address - Fax:
Practice Address - Street 1:1240 RIDGE RD
Practice Address - Street 2:
Practice Address - City:WAUKESHA
Practice Address - State:WI
Practice Address - Zip Code:53186-1425
Practice Address - Country:US
Practice Address - Phone:262-574-9342
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI27717207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI27717OtherSTATE LICENSE
WIB54735Medicare UPIN