Provider Demographics
NPI:1467439745
Name:MACK, JOSEPH MICHAEL (MD)
Entity type:Individual
Prefix:DR
First Name:JOSEPH
Middle Name:MICHAEL
Last Name:MACK
Suffix:
Gender:
Credentials:MD
Other - Prefix:
Other - First Name:JOE
Other - Middle Name:MICHAEL
Other - Last Name:MACK
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:2008 CARIBOU DR
Mailing Address - Street 2:
Mailing Address - City:FORT COLLINS
Mailing Address - State:CO
Mailing Address - Zip Code:80525-4325
Mailing Address - Country:US
Mailing Address - Phone:970-484-4757
Mailing Address - Fax:970-484-4759
Practice Address - Street 1:1024 S LEMAY AVE
Practice Address - Street 2:
Practice Address - City:FORT COLLINS
Practice Address - State:CO
Practice Address - Zip Code:80524-3929
Practice Address - Country:US
Practice Address - Phone:970-484-4757
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-12-28
Last Update Date:2025-03-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NECP10902085R0202X
WY17609C2085R0202X
COCDR.00045062085R0202X
GA582752085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA453088873PMedicaid