Provider Demographics
NPI:1669651618
Name:ALBERT C MAK MD INC
Entity Type:Organization
Organization Name:ALBERT C MAK MD INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MS
Authorized Official - First Name:ROSE MARIE
Authorized Official - Middle Name:
Authorized Official - Last Name:RIVERA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:805-577-8730
Mailing Address - Street 1:PO BOX 80520
Mailing Address - Street 2:
Mailing Address - City:SAN MARINO
Mailing Address - State:CA
Mailing Address - Zip Code:91118-8520
Mailing Address - Country:US
Mailing Address - Phone:805-577-8730
Mailing Address - Fax:805-991-4065
Practice Address - Street 1:707 S GARFIELD AVE
Practice Address - Street 2:BSMT
Practice Address - City:ALHAMBRA
Practice Address - State:CA
Practice Address - Zip Code:91801-5859
Practice Address - Country:US
Practice Address - Phone:805-577-8730
Practice Address - Fax:805-991-4065
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-10-26
Last Update Date:2020-03-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG793302085R0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2085R0001XAllopathic & Osteopathic PhysiciansRadiologyRadiation OncologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G793300Medicaid
CAW15436Medicare PIN
CA00G793300Medicaid