Basic Information
| Provider Information | |||||||||
| NPI: | 1508866948 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MACK | ||||||||
| FirstName: | DOMINIC | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 720 WESTVIEW DR SW STE 100 | ||||||||
| Address2: | |||||||||
| City: | ATLANTA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 303101458 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4047561400 | ||||||||
| FaxNumber: | 4047565274 | ||||||||
| Practice Location | |||||||||
| Address1: | 1513 EAST CLEVELAND AVE | ||||||||
| Address2: | BUILDING 500 | ||||||||
| City: | EAST POINT | ||||||||
| State: | GA | ||||||||
| PostalCode: | 30344 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4047521000 | ||||||||
| FaxNumber: | 4047521191 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/28/2005 | ||||||||
| LastUpdateDate: | 05/13/2019 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 031630 | GA | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 000433892 | 05 | GA | MEDICAID |