Provider Demographics
NPI:1477515294
Name:LACK, MICHAEL D (MD)
Entity type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:D
Last Name:LACK
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 1:4334 E HIGHLAND DR
Mailing Address - Street 2:
Mailing Address - City:JONESBORO
Mailing Address - State:AR
Mailing Address - Zip Code:72401-6621
Mailing Address - Country:US
Mailing Address - Phone:870-802-0012
Mailing Address - Fax:870-972-5140
Practice Address - Street 1:4334 E HIGHLAND DR
Practice Address - Street 2:
Practice Address - City:JONESBORO
Practice Address - State:AR
Practice Address - Zip Code:72401-6621
Practice Address - Country:US
Practice Address - Phone:870-802-0012
Practice Address - Fax:870-972-5140
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-04-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARC54202083X0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2083X0100XAllopathic & Osteopathic PhysiciansPreventive MedicineOccupational Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR03100011900OtherQUALCHOICE
AR03100011900OtherQUALCHOICE
AR53013Medicare ID - Type Unspecified