Healthcare Provider Details

I. General information

NPI: 1477515294
Provider Name (Legal Business Name): MICHAEL D LACK M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 04/05/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4334 E HIGHLAND DR
JONESBORO AR
72401-6621
US

IV. Provider business mailing address

4334 E HIGHLAND DR
JONESBORO AR
72401-6621
US

V. Phone/Fax

Practice location:
  • Phone: 870-802-0012
  • Fax: 870-972-5140
Mailing address:
  • Phone: 870-802-0012
  • Fax: 870-972-5140

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2083X0100X
TaxonomyOccupational Medicine Physician
License NumberC5420
License Number StateAR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: