Provider Demographics
NPI:1124148721
Name:SACK, ROBERT IRA (MD)
Entity type:Individual
Prefix:DR
First Name:ROBERT
Middle Name:IRA
Last Name:SACK
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
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Other - Credentials:
Mailing Address - Street 1:5410 AVENUE SIMONE
Mailing Address - Street 2:
Mailing Address - City:LUTZ
Mailing Address - State:FL
Mailing Address - Zip Code:33558-2828
Mailing Address - Country:US
Mailing Address - Phone:301-442-4158
Mailing Address - Fax:
Practice Address - Street 1:410 N PRINCE ST
Practice Address - Street 2:T W PONESSA AND ASSOCIATES
Practice Address - City:LANCASTER
Practice Address - State:PA
Practice Address - Zip Code:17603-3010
Practice Address - Country:US
Practice Address - Phone:717-560-7917
Practice Address - Fax:717-560-6452
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-29
Last Update Date:2016-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD4383062084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD512942Medicare ID - Type Unspecified