Healthcare Provider Details

I. General information

NPI: 1811041056
Provider Name (Legal Business Name): DAVID R MACK MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/23/2007
Last Update Date: 04/02/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

505 W NORTHERN LIGHTS BLVD
ANCHORAGE AK
99503-2552
US

IV. Provider business mailing address

505 W NORTHERN LIGHTS BLVD
ANCHORAGE AK
99503-2552
US

V. Phone/Fax

Practice location:
  • Phone: 907-302-8205
  • Fax:
Mailing address:
  • Phone: 907-302-8205
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License NumberMEDS 7369
License Number StateAK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: