Provider Demographics
NPI:1982866935
Name:MACK, TRACY T (MD)
Entity Type:Individual
Prefix:
First Name:TRACY
Middle Name:T
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 1:300 EAST 6TH STREET
Mailing Address - Street 2:
Mailing Address - City:TEXARKANA
Mailing Address - State:AR
Mailing Address - Zip Code:71854
Mailing Address - Country:US
Mailing Address - Phone:870-779-6004
Mailing Address - Fax:870-779-6119
Practice Address - Street 1:300 EAST 6TH STREET
Practice Address - Street 2:
Practice Address - City:TEXARKANA
Practice Address - State:AR
Practice Address - Zip Code:71854
Practice Address - Country:US
Practice Address - Phone:870-779-6004
Practice Address - Fax:870-779-6119
Is Sole Proprietor?:No
Enumeration Date:2008-07-01
Last Update Date:2020-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT64851207P00000X
GA67268207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine