Provider Demographics
NPI:1356662134
Name:MACK, FELICITY L (MD)
Entity Type:Individual
Prefix:
First Name:FELICITY
Middle Name:L
Last Name:MACK
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:460 PARK GROVE DR
Mailing Address - Street 2:
Mailing Address - City:KATY
Mailing Address - State:TX
Mailing Address - Zip Code:77450-1571
Mailing Address - Country:US
Mailing Address - Phone:413-862-2563
Mailing Address - Fax:203-493-8028
Practice Address - Street 1:460 PARK GROVE DR
Practice Address - Street 2:
Practice Address - City:KATY
Practice Address - State:TX
Practice Address - Zip Code:77450-1571
Practice Address - Country:US
Practice Address - Phone:413-862-2563
Practice Address - Fax:203-493-8028
Is Sole Proprietor?:Yes
Enumeration Date:2010-06-16
Last Update Date:2024-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXP1564207Q00000X
261QM1300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No261QM1300XAmbulatory Health Care FacilitiesClinic/CenterMulti-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX4166548Medicaid