Provider Demographics
NPI:1609875004
Name:MAK, MAN-SIAK (MD)
Entity Type:Individual
Prefix:DR
First Name:MAN-SIAK
Middle Name:
Last Name:MAK
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 1:3349 G STREET STE. F
Mailing Address - Street 2:
Mailing Address - City:MERCED
Mailing Address - State:CA
Mailing Address - Zip Code:95340
Mailing Address - Country:US
Mailing Address - Phone:209-349-8459
Mailing Address - Fax:209-580-4138
Practice Address - Street 1:3349 G STREET STE. F
Practice Address - Street 2:
Practice Address - City:MERCED
Practice Address - State:CA
Practice Address - Zip Code:95340
Practice Address - Country:US
Practice Address - Phone:209-349-8459
Practice Address - Fax:209-580-4138
Is Sole Proprietor?:Yes
Enumeration Date:2005-07-18
Last Update Date:2019-04-17
Deactivation Date:2006-03-16
Deactivation Code:
Reactivation Date:2006-03-21
Provider Licenses
StateLicense IDTaxonomies
CAA26785207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A267850Medicaid
A24961Medicare UPIN
00A267850Medicare ID - Type Unspecified