Provider Demographics
NPI:1326025784
Name:HADDOCK, MACK EVANS (CRNA)
Entity Type:Individual
Prefix:MR
First Name:MACK
Middle Name:EVANS
Last Name:HADDOCK
Suffix:
Gender:M
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:911 SOLEDAD WAY
Mailing Address - Street 2:
Mailing Address - City:THE VILLAGES
Mailing Address - State:FL
Mailing Address - Zip Code:32159-9112
Mailing Address - Country:US
Mailing Address - Phone:352-259-7483
Mailing Address - Fax:
Practice Address - Street 1:1160 SE 18TH PL
Practice Address - Street 2:OCALA ENDOSCOPY CENTER
Practice Address - City:OCALA
Practice Address - State:FL
Practice Address - Zip Code:34471-5422
Practice Address - Country:US
Practice Address - Phone:352-732-8905
Practice Address - Fax:352-732-2440
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-12-28
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL9201655367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
G3377Medicare ID - Type Unspecified