Healthcare Provider Details

I. General information

NPI: 1346390044
Provider Name (Legal Business Name): JASON MACK MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/12/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1901 1ST AVE DEPT OF PEDIATRICS ROOM 523
NEW YORK NY
10029-7404
US

IV. Provider business mailing address

253 W 123RD ST
NEW YORK NY
10027-5429
US

V. Phone/Fax

Practice location:
  • Phone: 212-423-6228
  • Fax:
Mailing address:
  • Phone: 212-423-6228
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number178505
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: