Healthcare Provider Details

I. General information

NPI: 1114160629
Provider Name (Legal Business Name): MACK DRAKE DO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/14/2009
Last Update Date: 05/25/2023
Certification Date: 05/25/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7101 JAHNKE RD
RICHMOND VA
23225-4017
US

IV. Provider business mailing address

PO BOX 3548
AUGUSTA GA
30914-3548
US

V. Phone/Fax

Practice location:
  • Phone: 706-863-9595
  • Fax: 706-868-8375
Mailing address:
  • Phone: 706-863-9595
  • Fax: 706-868-8375

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number0102206152
License Number StateVA
# 2
Primary TaxonomyY
Taxonomy Code2086S0102X
TaxonomySurgical Critical Care Physician
License Number0102206152
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: