Provider Demographics
NPI:1194983031
Name:SACK, KENT LEE (MD)
Entity type:Individual
Prefix:DR
First Name:KENT
Middle Name:LEE
Last Name:SACK
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 1:340 5TH AVE SOUTH
Mailing Address - Street 2:
Mailing Address - City:PACHERO
Mailing Address - State:CA
Mailing Address - Zip Code:94553
Mailing Address - Country:US
Mailing Address - Phone:925-685-8878
Mailing Address - Fax:
Practice Address - Street 1:340 5TH AVE SOUTH
Practice Address - Street 2:
Practice Address - City:PACHERO
Practice Address - State:CA
Practice Address - Zip Code:94553
Practice Address - Country:US
Practice Address - Phone:925-685-8878
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-05-28
Last Update Date:2008-05-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAC29667207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine