Provider Demographics
NPI:1225216997
Name:MACK, MICHAEL DEAN (DO)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:DEAN
Last Name:MACK
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 1:4578 ASHTON CIR
Mailing Address - Street 2:
Mailing Address - City:CRESTVIEW
Mailing Address - State:FL
Mailing Address - Zip Code:32536-2258
Mailing Address - Country:US
Mailing Address - Phone:515-290-2100
Mailing Address - Fax:
Practice Address - Street 1:4480 UTICA RIDGE RD
Practice Address - Street 2:
Practice Address - City:BETTENDORF
Practice Address - State:IA
Practice Address - Zip Code:52722-1644
Practice Address - Country:US
Practice Address - Phone:563-742-4850
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-02-05
Last Update Date:2016-01-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA3906207P00000X
FLOS12342207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine