Basic Information
| Provider Information | |||||||||
| NPI: | 1003803461 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MACK | ||||||||
| FirstName: | JEFFREY | ||||||||
| MiddleName: | T. | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2510 W DUNLAP AVE | ||||||||
| Address2: | STE 290 | ||||||||
| City: | PHOENIX | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 850212737 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6027890344 | ||||||||
| FaxNumber: | 6027898389 | ||||||||
| Practice Location | |||||||||
| Address1: | 4001 E SUNRISE DR STE 161 | ||||||||
| Address2: | |||||||||
| City: | TUCSON | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 857184324 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5204086955 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 09/30/2005 | ||||||||
| LastUpdateDate: | 01/27/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 01/27/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 32313 | AZ | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 840547 | 05 | AZ | MEDICAID |