Provider Demographics
NPI:1023008562
Name:LACK, ERNEST E (MD)
Entity Type:Individual
Prefix:
First Name:ERNEST
Middle Name:E
Last Name:LACK
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Mailing Address - Street 1:1201 SEVEN LOCKS RD
Mailing Address - Street 2:SUITE 200
Mailing Address - City:ROCKVILLE
Mailing Address - State:MD
Mailing Address - Zip Code:20854-2931
Mailing Address - Country:US
Mailing Address - Phone:301-652-5771
Mailing Address - Fax:301-652-6332
Practice Address - Street 1:110 IRVING ST NW
Practice Address - Street 2:
Practice Address - City:WASHINGTON
Practice Address - State:DC
Practice Address - Zip Code:20010-2976
Practice Address - Country:US
Practice Address - Phone:202-877-6190
Practice Address - Fax:202-877-3820
Is Sole Proprietor?:Yes
Enumeration Date:2005-10-26
Last Update Date:2010-12-02
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
DCMD25987207ZP0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ZP0102XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology & Clinical Pathology
Provider Identifiers
StateIdentifier IDID TypeIssuer
F83864Medicare UPIN
00B804P93Medicare ID - Type Unspecified