Provider Demographics
NPI:1487703153
Name:MACK, CANDRA LANETTE (MD)
Entity type:Individual
Prefix:
First Name:CANDRA
Middle Name:LANETTE
Last Name:MACK
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4152 BAKER STREET, NE
Mailing Address - Street 2:
Mailing Address - City:COVINGTON
Mailing Address - State:GA
Mailing Address - Zip Code:30014-1404
Mailing Address - Country:US
Mailing Address - Phone:770-788-1077
Mailing Address - Fax:770-805-9329
Practice Address - Street 1:4152 BAKER STREET, NE
Practice Address - Street 2:
Practice Address - City:COVINGTON
Practice Address - State:GA
Practice Address - Zip Code:30014-1404
Practice Address - Country:US
Practice Address - Phone:770-788-1077
Practice Address - Fax:770-805-9329
Is Sole Proprietor?:No
Enumeration Date:2007-01-10
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLTRN8908208000000X
GA61000208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA061000OtherMEDICAL LICENSE
GA510091718AMedicaid
GA510091718AMedicaid