Provider Demographics
NPI:1518105345
Name:T MATTHEW MAK MD INC
Entity Type:Organization
Organization Name:T MATTHEW MAK MD INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:T. MATTHEW
Authorized Official - Middle Name:
Authorized Official - Last Name:MAK
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:440-992-7788
Mailing Address - Street 1:2728 LAKE AVE
Mailing Address - Street 2:
Mailing Address - City:ASHTABULA
Mailing Address - State:OH
Mailing Address - Zip Code:44004-4960
Mailing Address - Country:US
Mailing Address - Phone:440-992-7788
Mailing Address - Fax:440-998-0388
Practice Address - Street 1:2728 LAKE AVE
Practice Address - Street 2:
Practice Address - City:ASHTABULA
Practice Address - State:OH
Practice Address - Zip Code:44004-4960
Practice Address - Country:US
Practice Address - Phone:440-992-7788
Practice Address - Fax:440-998-0388
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-02-02
Last Update Date:2009-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35044839174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0442444Medicaid
OH0732640001Medicare NSC
OH0442444Medicaid
OH0486603Medicare PIN