Provider Demographics
NPI:1770506958
Name:MACK, MATTHEW D (MD)
Entity Type:Individual
Prefix:DR
First Name:MATTHEW
Middle Name:D
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 1:180 MOUNT VERNON AVE
Mailing Address - Street 2:
Mailing Address - City:ROCHESTER
Mailing Address - State:NY
Mailing Address - Zip Code:14620-2344
Mailing Address - Country:US
Mailing Address - Phone:585-747-3297
Mailing Address - Fax:
Practice Address - Street 1:340 ARNETT BLVD
Practice Address - Street 2:
Practice Address - City:ROCHESTER
Practice Address - State:NY
Practice Address - Zip Code:14619-1147
Practice Address - Country:US
Practice Address - Phone:585-235-2250
Practice Address - Fax:585-235-0011
Is Sole Proprietor?:No
Enumeration Date:2006-07-26
Last Update Date:2019-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY252075208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice