Provider Demographics
NPI:1376545335
Name:FLACK, DAVID A (M D)
Entity Type:Individual
Prefix:
First Name:DAVID
Middle Name:A
Last Name:FLACK
Suffix:
Gender:M
Credentials:M D
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1107 BROOK AVE
Mailing Address - Street 2:
Mailing Address - City:WICHITA FALLS
Mailing Address - State:TX
Mailing Address - Zip Code:76301-5008
Mailing Address - Country:US
Mailing Address - Phone:940-322-8800
Mailing Address - Fax:940-322-8833
Practice Address - Street 1:1209 BROOK AVE
Practice Address - Street 2:
Practice Address - City:WICHITA FALLS
Practice Address - State:TX
Practice Address - Zip Code:76301-5601
Practice Address - Country:US
Practice Address - Phone:940-322-7284
Practice Address - Fax:940-322-8938
Is Sole Proprietor?:Yes
Enumeration Date:2005-06-02
Last Update Date:2008-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXG5046207ZP0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ZP0102XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology & Clinical Pathology
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXPO80P2466Medicaid
TX80P246OtherBLUE CROSS
TX80P246Medicare UPIN
TXPO80P2466Medicaid