Provider Demographics
NPI:1366679318
Name:MACK, DARREN JOSEPH (MD)
Entity Type:Individual
Prefix:DR
First Name:DARREN
Middle Name:JOSEPH
Last Name:MACK
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
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Other - Credentials:
Mailing Address - Street 1:367 S. GULPH RD
Mailing Address - Street 2:ATT: IPM CREDENTIALING
Mailing Address - City:KING OF PRUSSIA
Mailing Address - State:PA
Mailing Address - Zip Code:19406-3121
Mailing Address - Country:US
Mailing Address - Phone:803-716-8712
Mailing Address - Fax:
Practice Address - Street 1:770 MEDICAL PARK DR
Practice Address - Street 2:
Practice Address - City:AIKEN
Practice Address - State:SC
Practice Address - Zip Code:29801-6307
Practice Address - Country:US
Practice Address - Phone:803-716-8712
Practice Address - Fax:803-716-8713
Is Sole Proprietor?:No
Enumeration Date:2009-06-17
Last Update Date:2019-03-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA71606208800000X, 208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA202I345340Medicare PIN