Basic Information
| Provider Information | |||||||||
| NPI: | 1679555908 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MACK | ||||||||
| FirstName: | DAVID | ||||||||
| MiddleName: | A | ||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | D.O. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1810 E 19TH ST | ||||||||
| Address2: | SUITE 209 | ||||||||
| City: | THE DALLES | ||||||||
| State: | OR | ||||||||
| PostalCode: | 970583388 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5412965657 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1810 EAST 19TH ST | ||||||||
| Address2: | SUITE 209 | ||||||||
| City: | THE DALLES | ||||||||
| State: | OR | ||||||||
| PostalCode: | 97058 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5412965657 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 11/14/2005 | ||||||||
| LastUpdateDate: | 02/27/2008 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207V00000X | DO08469 | OR | Y | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology |
ID Information
| ID | Type | State | Issuer | Description | 227967 | 05 | OR | MEDICAID |