Provider Demographics
NPI:1972982650
Name:MACK, JOHNATHAN (MD)
Entity type:Individual
Prefix:DR
First Name:JOHNATHAN
Middle Name:
Last Name:MACK
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 1:55 FRUIT STREET
Mailing Address - Street 2:MASSACHUSETTS GENERAL HOSPITAL, BLOOD BANK, GRJ-238
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02114-2621
Mailing Address - Country:US
Mailing Address - Phone:617-726-3785
Mailing Address - Fax:
Practice Address - Street 1:55 FRUIT STREET
Practice Address - Street 2:MASSACHUSETTS GENERAL HOSPITAL, BLOOD BANK, GRJ-238
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02114
Practice Address - Country:US
Practice Address - Phone:617-726-3785
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-05-27
Last Update Date:2016-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA267360207RH0000X, 207ZB0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ZB0001XAllopathic & Osteopathic PhysiciansPathologyBlood Banking & Transfusion Medicine
No207RH0000XAllopathic & Osteopathic PhysiciansInternal MedicineHematology