Provider Demographics
NPI:1598852501
Name:TAM, DOMINIC WAI-HO (MD)
Entity Type:Individual
Prefix:
First Name:DOMINIC
Middle Name:WAI-HO
Last Name:TAM
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:PO BOX 39578
Mailing Address - Street 2:
Mailing Address - City:SOLON
Mailing Address - State:OH
Mailing Address - Zip Code:44139-0578
Mailing Address - Country:US
Mailing Address - Phone:440-572-3020
Mailing Address - Fax:216-765-8401
Practice Address - Street 1:16000 PEARL RD
Practice Address - Street 2:# 208
Practice Address - City:STRONGSVILLE
Practice Address - State:OH
Practice Address - Zip Code:44136-6082
Practice Address - Country:US
Practice Address - Phone:440-572-3020
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-10
Last Update Date:2017-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35043641207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0426640Medicaid
OHTA0464888Medicare ID - Type Unspecified
OH0426640Medicaid