Provider Demographics
NPI:1811041056
Name:MACK, DAVID R (MD)
Entity Type:Individual
Prefix:
First Name:DAVID
Middle Name:R
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 1:505 W NORTHERN LIGHTS BLVD
Mailing Address - Street 2:
Mailing Address - City:ANCHORAGE
Mailing Address - State:AK
Mailing Address - Zip Code:99503-2552
Mailing Address - Country:US
Mailing Address - Phone:907-302-8205
Mailing Address - Fax:
Practice Address - Street 1:505 W NORTHERN LIGHTS BLVD
Practice Address - Street 2:
Practice Address - City:ANCHORAGE
Practice Address - State:AK
Practice Address - Zip Code:99503-2552
Practice Address - Country:US
Practice Address - Phone:907-302-8205
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-01-23
Last Update Date:2017-04-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AKMEDS 73692084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC13580Medicaid
NDP00230275OtherRAILROAD MEDICARE
NCI35159Medicare UPIN
NC13580Medicaid