Provider Demographics
NPI:1114131448
Name:PACK, DAVID ARTHUR (MD)
Entity Type:Individual
Prefix:DR
First Name:DAVID
Middle Name:ARTHUR
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 1:697 MISTLETOE ST
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:OH
Mailing Address - Zip Code:43230-4826
Mailing Address - Country:US
Mailing Address - Phone:614-476-2374
Mailing Address - Fax:
Practice Address - Street 1:1430 COLUMBUS AVE
Practice Address - Street 2:
Practice Address - City:WASHINGTON COURT HOUSE
Practice Address - State:OH
Practice Address - Zip Code:43160-1703
Practice Address - Country:US
Practice Address - Phone:740-333-2780
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-09
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35-03-0158-P207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY64154214Medicaid
OH0112265Medicaid
KY1838501Medicare ID - Type Unspecified
C00790Medicare UPIN
OH0147364Medicare ID - Type Unspecified