Provider Demographics
NPI:1174606602
Name:HACKMAN, MARK S (MD)
Entity type:Individual
Prefix:
First Name:MARK
Middle Name:S
Last Name:HACKMAN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10777 W TWAIN AVENUE
Mailing Address - Street 2:SUITE 225
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89135
Mailing Address - Country:US
Mailing Address - Phone:702-839-0946
Mailing Address - Fax:702-839-0149
Practice Address - Street 1:525 N 18TH STREET
Practice Address - Street 2:SUITE 302
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85006-4102
Practice Address - Country:US
Practice Address - Phone:602-257-0200
Practice Address - Fax:602-257-0201
Is Sole Proprietor?:No
Enumeration Date:2006-10-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ34493207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
GAC16421Medicare UPIN