Provider Demographics
NPI:1346390044
Name:MACK, JASON (MD)
Entity Type:Individual
Prefix:DR
First Name:JASON
Middle Name:
Last Name:MACK
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 1:253 W 123RD ST
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10027-5429
Mailing Address - Country:US
Mailing Address - Phone:212-423-6228
Mailing Address - Fax:
Practice Address - Street 1:1901 1ST AVE
Practice Address - Street 2:DEPT OF PEDIATRICS ROOM 523
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10029-7404
Practice Address - Country:US
Practice Address - Phone:212-423-6228
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY178505208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics