Provider Demographics
NPI:1508866948
Name:MACK, DOMINIC (MD)
Entity Type:Individual
Prefix:
First Name:DOMINIC
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 1:720 WESTVIEW DR SW STE 100
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30310-1458
Mailing Address - Country:US
Mailing Address - Phone:404-756-1400
Mailing Address - Fax:404-756-5274
Practice Address - Street 1:1513 EAST CLEVELAND AVE
Practice Address - Street 2:BUILDING 500
Practice Address - City:EAST POINT
Practice Address - State:GA
Practice Address - Zip Code:30344
Practice Address - Country:US
Practice Address - Phone:404-752-1000
Practice Address - Fax:404-752-1191
Is Sole Proprietor?:Yes
Enumeration Date:2005-07-28
Last Update Date:2019-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA031630207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000433892Medicaid
GA000433892Medicaid
08BBVSDMedicare ID - Type Unspecified