Provider Demographics
NPI:1801826151
Name:MACK, JOHN B (MD)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:B
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:PO BOX 610393
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75261-0393
Mailing Address - Country:US
Mailing Address - Phone:903-232-8501
Mailing Address - Fax:903-232-8226
Practice Address - Street 1:707 HOLLYBROOK DR
Practice Address - Street 2:
Practice Address - City:LONGVIEW
Practice Address - State:TX
Practice Address - Zip Code:75605-2410
Practice Address - Country:US
Practice Address - Phone:903-753-4666
Practice Address - Fax:903-753-6634
Is Sole Proprietor?:No
Enumeration Date:2006-07-03
Last Update Date:2019-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXH6396208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX099133305Medicaid
TX099133305Medicaid
TXTXB147322Medicare PIN