Provider Demographics
NPI:1548558612
Name:PACK, PHILIP PAUL III (DO)
Entity type:Individual
Prefix:DR
First Name:PHILIP
Middle Name:PAUL
Last Name:PACK
Suffix:III
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:925 DENNISON HTS
Mailing Address - Street 2:
Mailing Address - City:SOUTHSIDE
Mailing Address - State:AR
Mailing Address - Zip Code:72501-8943
Mailing Address - Country:US
Mailing Address - Phone:786-519-9572
Mailing Address - Fax:
Practice Address - Street 1:415 ALLEN ST
Practice Address - Street 2:
Practice Address - City:BATESVILLE
Practice Address - State:AR
Practice Address - Zip Code:72501-6958
Practice Address - Country:US
Practice Address - Phone:870-307-3790
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-07-11
Last Update Date:2024-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN02007472A208600000X
FLUO3383208600000X
FLOS14245208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery