Provider Demographics
NPI:1356985105
Name:MACK, ROBERT THOMAS (MD)
Entity type:Individual
Prefix:DR
First Name:ROBERT
Middle Name:THOMAS
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 1:1311 WESTVIEW DR
Mailing Address - Street 2:
Mailing Address - City:BERKELEY
Mailing Address - State:CA
Mailing Address - Zip Code:94705-1652
Mailing Address - Country:US
Mailing Address - Phone:510-967-9378
Mailing Address - Fax:
Practice Address - Street 1:1311 WESTVIEW DR
Practice Address - Street 2:
Practice Address - City:BERKELEY
Practice Address - State:CA
Practice Address - Zip Code:94705-1652
Practice Address - Country:US
Practice Address - Phone:510-967-9378
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-11-05
Last Update Date:2019-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG25338208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice