Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 207Q00000X | Family Doctor | 35052196 | OH |
Y | 207QG0300X | Family Doctor - Geriatric Medicine | 35052196 | OH |
NPI | 1316980311 |
---|---|
Provider Name | Dr. Donald Owen Mack |
First Address | Columbus, OH 43202-1559 |
Second Address | Columbus, OH 43201-1101 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 14/06/2006 |
Last Update Date | 01/03/2021 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
0634899 | (05) | OH |
C03241 | (02) |