Provider Demographics
NPI:1598704736
Name:MACK, WILLIAM JOSEPH (MD)
Entity Type:Individual
Prefix:DR
First Name:WILLIAM
Middle Name:JOSEPH
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 1:11111 NALL AVE
Mailing Address - Street 2:SUITE 103
Mailing Address - City:LEAWOOD
Mailing Address - State:KS
Mailing Address - Zip Code:66211-1924
Mailing Address - Country:US
Mailing Address - Phone:913-314-3495
Mailing Address - Fax:
Practice Address - Street 1:11111 NALL AVE
Practice Address - Street 2:SUITE 103
Practice Address - City:LEAWOOD
Practice Address - State:KS
Practice Address - Zip Code:66211-1924
Practice Address - Country:US
Practice Address - Phone:913-314-3495
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-05
Last Update Date:2012-06-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS04-354862084P0800X
MO20110368132084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry