Healthcare Provider Details

I. General information

NPI: 1326025784
Provider Name (Legal Business Name): MACK EVANS HADDOCK CRNA
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 12/28/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1160 SE 18TH PL OCALA ENDOSCOPY CENTER
OCALA FL
34471-5422
US

IV. Provider business mailing address

911 SOLEDAD WAY
THE VILLAGES FL
32159-9112
US

V. Phone/Fax

Practice location:
  • Phone: 352-732-8905
  • Fax: 352-732-2440
Mailing address:
  • Phone: 352-259-7483
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number9201655
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: