Provider Demographics
NPI:1760577506
Name:MACK, GREGORY J (DPM)
Entity Type:Individual
Prefix:
First Name:GREGORY
Middle Name:J
Last Name:MACK
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 392
Mailing Address - Street 2:
Mailing Address - City:MENOMONIE
Mailing Address - State:WI
Mailing Address - Zip Code:54751-0392
Mailing Address - Country:US
Mailing Address - Phone:715-235-4274
Mailing Address - Fax:715-235-9644
Practice Address - Street 1:201 CEDAR FALLS RD
Practice Address - Street 2:
Practice Address - City:MENOMONIE
Practice Address - State:WI
Practice Address - Zip Code:54751-1270
Practice Address - Country:US
Practice Address - Phone:715-235-4274
Practice Address - Fax:715-235-9644
Is Sole Proprietor?:No
Enumeration Date:2006-10-04
Last Update Date:2022-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI651025213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI43214300Medicaid
WI1760577506Medicare NSC
WI43214300Medicaid