Provider Demographics
NPI:1558586388
Name:MACK, PATRICE C (MD, PA)
Entity type:Individual
Prefix:DR
First Name:PATRICE
Middle Name:C
Last Name:MACK
Suffix:
Gender:F
Credentials:MD, PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:801 LAUREL OAK DR STE 715
Mailing Address - Street 2:
Mailing Address - City:NAPLES
Mailing Address - State:FL
Mailing Address - Zip Code:34108-2754
Mailing Address - Country:US
Mailing Address - Phone:239-254-0535
Mailing Address - Fax:239-254-0532
Practice Address - Street 1:801 LAUREL OAK DR STE 715
Practice Address - Street 2:
Practice Address - City:NAPLES
Practice Address - State:FL
Practice Address - Zip Code:34108
Practice Address - Country:US
Practice Address - Phone:239-254-0535
Practice Address - Fax:239-254-0532
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-16
Last Update Date:2018-07-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME24010174400000X, 2084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
No174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLME24010Medicare UPIN