Provider Demographics
NPI:1528169513
Name:MACK, GREGORY R (MD)
Entity type:Individual
Prefix:DR
First Name:GREGORY
Middle Name:R
Last Name:MACK
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:8008 FROST ST
Mailing Address - Street 2:SUITE 403
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92123-4205
Mailing Address - Country:US
Mailing Address - Phone:858-715-9200
Mailing Address - Fax:858-715-1230
Practice Address - Street 1:8008 FROST ST
Practice Address - Street 2:SUITE 403
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92123-4205
Practice Address - Country:US
Practice Address - Phone:858-715-9200
Practice Address - Fax:858-715-1230
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-25
Last Update Date:2013-08-06
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
CAG375472086S0105X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2086S0105XAllopathic & Osteopathic PhysiciansSurgerySurgery of the Hand
Provider Identifiers
StateIdentifier IDID TypeIssuer
W19719OtherMEDICARE PTAN
CA00G375470Medicaid
CA00G375470Medicaid
CAA91902Medicare UPIN
CAG37547Medicare ID - Type UnspecifiedSTATE LICENSE