Healthcare Provider Details

I. General information

NPI: 1770506958
Provider Name (Legal Business Name): MATTHEW D MACK MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/26/2006
Last Update Date: 04/15/2025
Certification Date: 04/15/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

340 ARNETT BLVD
ROCHESTER NY
14619-1147
US

IV. Provider business mailing address

180 MOUNT VERNON AVE
ROCHESTER NY
14620-2344
US

V. Phone/Fax

Practice location:
  • Phone: 585-235-2250
  • Fax: 585-235-0011
Mailing address:
  • Phone: 585-747-3297
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number252075
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: