Provider Demographics
NPI:1124032990
Name:TACK, DAVID ALAN (MD)
Entity Type:Individual
Prefix:DR
First Name:DAVID
Middle Name:ALAN
Last Name:TACK
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 1:227 ST ALBANS PL
Mailing Address - Street 2:
Mailing Address - City:CARSON CITY
Mailing Address - State:NV
Mailing Address - Zip Code:89703-4546
Mailing Address - Country:US
Mailing Address - Phone:775-841-5259
Mailing Address - Fax:
Practice Address - Street 1:1100 S CARSON ST
Practice Address - Street 2:
Practice Address - City:CARSON CITY
Practice Address - State:NV
Practice Address - Zip Code:89701-5232
Practice Address - Country:US
Practice Address - Phone:775-883-7811
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-28
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV11209207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV11209OtherNV STATE MED. LIC #
NVA23127Medicare UPIN