Basic Information
| Provider Information | |||||||||
| NPI: | 1114999000 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MACKOOL | ||||||||
| FirstName: | BONNIE | ||||||||
| MiddleName: | TERESA | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 9142 | ||||||||
| Address2: | |||||||||
| City: | CHARLESTOWN | ||||||||
| State: | MA | ||||||||
| PostalCode: | 021299142 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6177240287 | ||||||||
| FaxNumber: | 6177262894 | ||||||||
| Practice Location | |||||||||
| Address1: | 50 STANIFORD ST | ||||||||
| Address2: | SUITE 200 | ||||||||
| City: | BOSTON | ||||||||
| State: | MA | ||||||||
| PostalCode: | 021142517 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6177262914 | ||||||||
| FaxNumber: | 6177242135 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/03/2006 | ||||||||
| LastUpdateDate: | 11/30/2012 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207N00000X | 76647 | MA | Y | Allopathic & Osteopathic Physicians | Dermatology | 207N00000X | G81270 | CA | N | Allopathic & Osteopathic Physicians | Dermatology |
ID Information
| ID | Type | State | Issuer | Description | 3107621 | 05 | MA | MEDICAID | J13548 | 01 | MA | BCBS MA | OTHER | 729619 | 01 | MA | TUFTS HEALTH PLAN | OTHER |