Provider Demographics
NPI:1386912129
Name:MACK, THOMAS MCCULLOCH (MD, MPH)
Entity type:Individual
Prefix:
First Name:THOMAS
Middle Name:MCCULLOCH
Last Name:MACK
Suffix:
Gender:M
Credentials:MD, MPH
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Other - Middle Name:
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Mailing Address - Street 1:1441 EASTLAKE AVE
Mailing Address - Street 2:RM 4453
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90089-0112
Mailing Address - Country:US
Mailing Address - Phone:323-865-0445
Mailing Address - Fax:323-865-0141
Practice Address - Street 1:1441 EASTLAKE AVE
Practice Address - Street 2:RM 4453
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90089-0112
Practice Address - Country:US
Practice Address - Phone:323-865-0445
Practice Address - Fax:323-865-0141
Is Sole Proprietor?:Yes
Enumeration Date:2011-12-08
Last Update Date:2011-12-08
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
CAG11518207R00000X, 2083P0901X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2083P0901XAllopathic & Osteopathic PhysiciansPreventive MedicinePublic Health & General Preventive Medicine
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine