Provider Demographics
NPI:1366416232
Name:MACKETT, CHARLES W III (MD)
Entity type:Individual
Prefix:DR
First Name:CHARLES
Middle Name:W
Last Name:MACKETT
Suffix:III
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
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Other - Credentials:
Mailing Address - Street 1:1555 INDIAN RIVER BLVD STE B210
Mailing Address - Street 2:
Mailing Address - City:VERO BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32960-7113
Mailing Address - Country:US
Mailing Address - Phone:772-257-8224
Mailing Address - Fax:772-252-3245
Practice Address - Street 1:1400 27TH ST
Practice Address - Street 2:
Practice Address - City:VERO BEACH
Practice Address - State:FL
Practice Address - Zip Code:32960-0303
Practice Address - Country:US
Practice Address - Phone:772-257-8224
Practice Address - Fax:772-252-3245
Is Sole Proprietor?:No
Enumeration Date:2006-02-15
Last Update Date:2025-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD425999174400000X
FLME107676207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA101235908Medicaid
FLME107676OtherMEDICAL LICENSE
FLD0117ZMedicare PIN
PA090139Medicare ID - Type Unspecified