Provider Demographics
NPI:1326571779
Name:MACK, JEFFERY (MD)
Entity Type:Individual
Prefix:
First Name:JEFFERY
Middle Name:
Last Name:MACK
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:11001 EXECUTIVE CENTER DR STE 200
Mailing Address - Street 2:
Mailing Address - City:LITTLE ROCK
Mailing Address - State:AR
Mailing Address - Zip Code:72211-4393
Mailing Address - Country:US
Mailing Address - Phone:501-851-7402
Mailing Address - Fax:501-851-4753
Practice Address - Street 1:1001 SCHNEIDER DR
Practice Address - Street 2:
Practice Address - City:MALVERN
Practice Address - State:AR
Practice Address - Zip Code:72104-4811
Practice Address - Country:US
Practice Address - Phone:501-851-7402
Practice Address - Fax:501-851-4753
Is Sole Proprietor?:Yes
Enumeration Date:2017-04-04
Last Update Date:2022-10-06
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
ARE-13380207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine