Healthcare Provider Details

I. General information

NPI: 1720124555
Provider Name (Legal Business Name): PORSHIA MACK M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/29/2007
Last Update Date: 01/06/2022
Certification Date: 01/06/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

22331 MISSION BLVD
HAYWARD CA
94541-3911
US

IV. Provider business mailing address

22331 MISSION BLVD
HAYWARD CA
94541-3911
US

V. Phone/Fax

Practice location:
  • Phone: 510-471-5880
  • Fax:
Mailing address:
  • Phone: 510-471-5880
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number231308
License Number StateNY
# 2
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberA88058
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: