Provider Demographics
NPI:1679570816
Name:MACK, WILLIAM P (MD)
Entity Type:Individual
Prefix:
First Name:WILLIAM
Middle Name:P
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 1:3109 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
Is Sole Proprietor?:No
Enumeration Date:2005-07-01
Last Update Date:2017-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME65603207W00000X, 207WX0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207WX0200XAllopathic & Osteopathic PhysiciansOphthalmologyOphthalmic Plastic and Reconstructive Surgery
No207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL2074423OtherAETNA
FL250029900Medicaid
FL5204189OtherAETNA
NY6012101OtherGHI
FL31233OtherBCBS FLORIDA
FL0805198OtherUNITED HEALTHCARE
FL0805198OtherUNITED HEALTHCARE
FL31233ZMedicare PIN
FLG20201Medicare UPIN
GA180034714Medicare PIN
FL250029900Medicaid