Provider Demographics
NPI:1760470686
Name:PACKER, MARK D (MD)
Entity Type:Individual
Prefix:DR
First Name:MARK
Middle Name:D
Last Name:PACKER
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 1:607 S NEW BALLAS RD
Mailing Address - Street 2:SUITE 2300
Mailing Address - City:ST LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63141-8234
Mailing Address - Country:US
Mailing Address - Phone:314-251-6394
Mailing Address - Fax:314-251-4235
Practice Address - Street 1:607 S NEW BALLAS RD
Practice Address - Street 2:SUITE 2300
Practice Address - City:ST LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63141-8234
Practice Address - Country:US
Practice Address - Phone:314-251-6394
Practice Address - Fax:314-251-4235
Is Sole Proprietor?:No
Enumeration Date:2005-10-13
Last Update Date:2017-07-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2016009560174400000X, 207Y00000X, 207YX0901X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207YX0901XAllopathic & Osteopathic PhysiciansOtolaryngologyOtology & Neurotology
No174400000XOther Service ProvidersSpecialist
No207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO138830043Medicare PIN