Provider Demographics
NPI:1427007798
Name:MAK, KENNETH W (MD)
Entity Type:Individual
Prefix:
First Name:KENNETH
Middle Name:W
Last Name:MAK
Suffix:
Gender:M
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 1:1541 FLORIDA AVE
Mailing Address - Street 2:200
Mailing Address - City:MODESTO
Mailing Address - State:CA
Mailing Address - Zip Code:95350-4429
Mailing Address - Country:US
Mailing Address - Phone:209-577-3388
Mailing Address - Fax:209-523-0764
Practice Address - Street 1:1541 FLORIDA AVE
Practice Address - Street 2:301
Practice Address - City:MODESTO
Practice Address - State:CA
Practice Address - Zip Code:95350-4429
Practice Address - Country:US
Practice Address - Phone:209-577-3388
Practice Address - Fax:209-523-0764
Is Sole Proprietor?:No
Enumeration Date:2006-05-06
Last Update Date:2021-12-21
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
CAA55527207Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A555270Medicaid
CACD069AOtherGROUP MEDICARE PTAN
CABC039ZMedicare PIN
CA00A555270Medicaid