Provider Demographics
NPI:1669443370
Name:MACK, LEO W JR (MD)
Entity Type:Individual
Prefix:
First Name:LEO
Middle Name:W
Last Name:MACK
Suffix:JR
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 1:5791 NEW COPELAND RD
Mailing Address - Street 2:
Mailing Address - City:TYLER
Mailing Address - State:TX
Mailing Address - Zip Code:75703-3905
Mailing Address - Country:US
Mailing Address - Phone:903-630-7007
Mailing Address - Fax:903-630-7072
Practice Address - Street 1:5791 NEW COPELAND RD
Practice Address - Street 2:
Practice Address - City:TYLER
Practice Address - State:TX
Practice Address - Zip Code:75703-3905
Practice Address - Country:US
Practice Address - Phone:903-630-7007
Practice Address - Fax:903-630-7072
Is Sole Proprietor?:No
Enumeration Date:2006-01-30
Last Update Date:2022-04-25
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
TXE4001207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX135428409Medicaid
TX135428409Medicaid