Provider Demographics
NPI:1689654592
Name:MAC, IVAN (MD)
Entity Type:Individual
Prefix:DR
First Name:IVAN
Middle Name:
Last Name:MAC
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 1:630 COMFORT LN
Mailing Address - Street 2:
Mailing Address - City:MONROE
Mailing Address - State:NC
Mailing Address - Zip Code:28112-6199
Mailing Address - Country:US
Mailing Address - Phone:704-289-5455
Mailing Address - Fax:704-291-2207
Practice Address - Street 1:630 COMFORT LN
Practice Address - Street 2:
Practice Address - City:MONROE
Practice Address - State:NC
Practice Address - Zip Code:28112-6199
Practice Address - Country:US
Practice Address - Phone:704-289-5455
Practice Address - Fax:704-291-2207
Is Sole Proprietor?:No
Enumeration Date:2006-01-18
Last Update Date:2010-07-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC200401094207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC89138MJMedicaid
I19442Medicare UPIN
NC89138MJMedicaid