Provider Demographics
NPI:1669682399
Name:WILLIAM MACK M D P A
Entity Type:Organization
Organization Name:WILLIAM MACK M D P A
Other - Org Name:WILLIAM P MACK MD
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:WILLIAM
Authorized Official - Middle Name:PAUL
Authorized Official - Last Name:MACK
Authorized Official - Suffix:
Authorized Official - Credentials:MD, PA
Authorized Official - Phone:813-875-5437
Mailing Address - Street 1:3109 W. AZEELE STREET
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33609
Mailing Address - Country:US
Mailing Address - Phone:813-875-5437
Mailing Address - Fax:813-873-9373
Practice Address - Street 1:3109 W. AZEELE STREET
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33609
Practice Address - Country:US
Practice Address - Phone:813-875-5437
Practice Address - Fax:813-873-9373
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-23
Last Update Date:2011-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLK8877Medicare PIN