Individual
DR. GORDON K MACK
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
MD
Contact information
Practice address
100 E IDAHO ST, SUITE 304, BOISE, ID 83712-6267
(208) 381-7384
(208) 381-7387
Mailing address
190 E BANNOCK ST, BOISE, ID 83712-6241
(208) 381-2222
Taxonomy
Speciality
Code
Description
License number
State
2080P0202X
Pediatric Cardiology Physician
7320207-1205
UT
2080P0202X
Pediatric Cardiology Physician
Primary
M-12151
ID
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
1982937058
—
ID
Enumeration date
09/08/2009
Last updated
02/05/2014
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