Provider Demographics
NPI:1053546507
Name:MACKIE, CRYSTAL MONIQUE (MD)
Entity type:Individual
Prefix:DR
First Name:CRYSTAL
Middle Name:MONIQUE
Last Name:MACKIE
Suffix:
Gender:F
Credentials:MD
Other - Prefix:DR
Other - First Name:CRYSTAL
Other - Middle Name:MONIQUE
Other - Last Name:DAVIS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:PO BOX 60447
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28260-0447
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:7903 PROVIDENCE RD STE 100
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28277-9763
Practice Address - Country:US
Practice Address - Phone:704-316-4460
Practice Address - Fax:704-316-4466
Is Sole Proprietor?:Yes
Enumeration Date:2009-05-27
Last Update Date:2021-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DCMD040888207Q00000X
NC202001935207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine