Provider Demographics
NPI:1174881601
Name:MACIAS, MARIO ALEJANDRO II (DO)
Entity type:Individual
Prefix:
First Name:MARIO
Middle Name:ALEJANDRO
Last Name:MACIAS
Suffix:II
Gender:M
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:PO BOX 777
Mailing Address - Street 2:
Mailing Address - City:RICHLAND
Mailing Address - State:MO
Mailing Address - Zip Code:65556-0777
Mailing Address - Country:US
Mailing Address - Phone:877-406-2662
Mailing Address - Fax:
Practice Address - Street 1:3870 COLUMBIA AVE
Practice Address - Street 2:
Practice Address - City:OSAGE BEACH
Practice Address - State:MO
Practice Address - Zip Code:65065-8689
Practice Address - Country:US
Practice Address - Phone:877-406-2662
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-05-03
Last Update Date:2022-05-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOS017813207V00000X
MO2021012099207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGroup - Single Specialty