Healthcare Provider Details

I. General information

NPI: 1568676823
Provider Name (Legal Business Name): DAVID K PACK M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/09/2007
Last Update Date: 02/19/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6185 BUFORD HWY BLDG G
NORCROSS GA
30071-2350
US

IV. Provider business mailing address

4432 DERWENT DR NE
ROSWELL GA
30075-1986
US

V. Phone/Fax

Practice location:
  • Phone: 770-446-0929
  • Fax: 770-446-6977
Mailing address:
  • Phone: 770-992-4621
  • Fax: 770-992-4621

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225400000X
TaxonomyRehabilitation Practitioner
License Number18829
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: