Provider Demographics
NPI:1043284334
Name:PACK, EDMOND ELIAS (MD)
Entity Type:Individual
Prefix:
First Name:EDMOND
Middle Name:ELIAS
Last Name:PACK
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8906 SPANISH RIDGE AVE STE 202
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89148-1319
Mailing Address - Country:US
Mailing Address - Phone:702-330-3102
Mailing Address - Fax:702-912-4994
Practice Address - Street 1:8285 W ARBY AVE STE 280
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89113-2246
Practice Address - Country:US
Practice Address - Phone:702-862-8862
Practice Address - Fax:702-862-8774
Is Sole Proprietor?:Yes
Enumeration Date:2006-02-14
Last Update Date:2020-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV9904207V00000X, 207VX0201X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
No207VX0201XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGynecologic Oncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV1043284334Medicaid
NV1043284334Medicaid
NVV104084Medicare PIN