Provider Demographics
NPI:1548572191
Name:PACK, JEFFREY DOUGLAS (MD)
Entity Type:Individual
Prefix:
First Name:JEFFREY
Middle Name:DOUGLAS
Last Name:PACK
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 1:2211 LOMAS BLVD NE
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87106-2719
Mailing Address - Country:US
Mailing Address - Phone:505-272-2610
Mailing Address - Fax:505-272-1300
Practice Address - Street 1:2211 LOMAS BLVD NE
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87106-2719
Practice Address - Country:US
Practice Address - Phone:505-272-2610
Practice Address - Fax:505-272-1300
Is Sole Proprietor?:No
Enumeration Date:2010-07-12
Last Update Date:2015-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMMD2014-0369207L00000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program