Provider Demographics
NPI:1184654972
Name:PACK, JOHN JOSEPH (MD)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:JOSEPH
Last Name:PACK
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 928
Mailing Address - Street 2:
Mailing Address - City:MANHATTAN BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:90267
Mailing Address - Country:US
Mailing Address - Phone:310-822-8584
Mailing Address - Fax:310-822-9924
Practice Address - Street 1:4560 ADMIRALTY WAY
Practice Address - Street 2:SUITE 356
Practice Address - City:MARINA DEL REY
Practice Address - State:CA
Practice Address - Zip Code:90292
Practice Address - Country:US
Practice Address - Phone:310-822-8584
Practice Address - Fax:310-822-9924
Is Sole Proprietor?:No
Enumeration Date:2006-07-04
Last Update Date:2009-12-10
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
CAG078330207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
G78330Medicare ID - Type Unspecified
G04305Medicare UPIN