Provider Demographics
NPI:1144289752
Name:MACK, YVONNE (MD)
Entity type:Individual
Prefix:DR
First Name:YVONNE
Middle Name:
Last Name:MACK
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:200 QUEENS RD
Mailing Address - Street 2:SUITE 400
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28204-3252
Mailing Address - Country:US
Mailing Address - Phone:704-333-7376
Mailing Address - Fax:704-333-3397
Practice Address - Street 1:182 VIRGINIA ST
Practice Address - Street 2:
Practice Address - City:BOONE
Practice Address - State:NC
Practice Address - Zip Code:28607-5043
Practice Address - Country:US
Practice Address - Phone:828-262-4342
Practice Address - Fax:828-262-4414
Is Sole Proprietor?:No
Enumeration Date:2006-03-22
Last Update Date:2012-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC348782085R0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0001XAllopathic & Osteopathic PhysiciansRadiologyRadiation Oncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC1523935007OtherCIGNA
NC1093AOtherBLUE CROSS
NC1003051OtherUNITED HEALTHCARE
NCA8656OtherMEDCOST
NC891093AMedicaid
NC2247979BMedicare ID - Type Unspecified
NC891093AMedicaid
NCA8656OtherMEDCOST