Provider Demographics
NPI:1114160629
Name:DRAKE, MACK (DO)
Entity Type:Individual
Prefix:
First Name:MACK
Middle Name:
Last Name:DRAKE
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 3548
Mailing Address - Street 2:
Mailing Address - City:AUGUSTA
Mailing Address - State:GA
Mailing Address - Zip Code:30914-3548
Mailing Address - Country:US
Mailing Address - Phone:706-863-9595
Mailing Address - Fax:706-868-8375
Practice Address - Street 1:7101 JAHNKE RD
Practice Address - Street 2:
Practice Address - City:RICHMOND
Practice Address - State:VA
Practice Address - Zip Code:23225-4017
Practice Address - Country:US
Practice Address - Phone:706-863-9595
Practice Address - Fax:706-868-8375
Is Sole Proprietor?:No
Enumeration Date:2009-04-14
Last Update Date:2023-05-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0102206152208600000X, 2086S0102X
KY037862086S0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2086S0102XAllopathic & Osteopathic PhysiciansSurgerySurgical Critical Care
No208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
NCNN2984AOtherMEDICARE
NC1114160629Medicaid
NC19XAVOtherBCBS OF NC