Healthcare Provider Details

I. General information

NPI: 1811446768
Provider Name (Legal Business Name): DAVID A SACK MD A PROFESSIONAL MEDICAL CORPORATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/03/2016
Last Update Date: 01/24/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2515 WILSHIRE BLVD
SANTA MONICA CA
90403-4615
US

IV. Provider business mailing address

PO BOX 671387
DALLAS TX
75267-1387
US

V. Phone/Fax

Practice location:
  • Phone: 866-595-3105
  • Fax: 424-272-9302
Mailing address:
  • Phone: 615-567-7282
  • Fax: 615-261-8912

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207RA0401X
TaxonomyAddiction Medicine (Internal Medicine) Physician
License NumberG88361
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code2084P0802X
TaxonomyAddiction Psychiatry Physician
License Number20A13416
License Number StateCA

VIII. Authorized Official

Name: MRS. CHERYL MAPLESDEN
Title or Position: SR DIRECTOR RCM
Credential: CPC,CHC,CHPC
Phone: 615-510-3078