Provider Demographics
NPI:1174695829
Name:PACK, WAYNE LAMONT JR (MD)
Entity type:Individual
Prefix:
First Name:WAYNE
Middle Name:LAMONT
Last Name:PACK
Suffix:JR
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:W.
Other - Middle Name:LAMONT
Other - Last Name:PACK
Other - Suffix:JR
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:1800 HARRISON ST FL 7
Mailing Address - Street 2:
Mailing Address - City:OAKLAND
Mailing Address - State:CA
Mailing Address - Zip Code:94612-3429
Mailing Address - Country:US
Mailing Address - Phone:510-625-6262
Mailing Address - Fax:
Practice Address - Street 1:2200 OFARRELL ST
Practice Address - Street 2:
Practice Address - City:SAN FRANCISCO
Practice Address - State:CA
Practice Address - Zip Code:94115-3357
Practice Address - Country:US
Practice Address - Phone:415-833-2000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-11-15
Last Update Date:2015-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG63470207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G634700Medicaid
F17323Medicare UPIN
00G634700Medicare ID - Type Unspecified