Provider Demographics
NPI:1679599450
Name:MAK, TAI-HUNG MATTHEW (MD)
Entity Type:Individual
Prefix:
First Name:TAI-HUNG
Middle Name:MATTHEW
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 1:2728 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:440-992-0388
Is Sole Proprietor?:No
Enumeration Date:2006-07-14
Last Update Date:2008-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35044839207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH341572119 00OtherBUC
OH0442444Medicaid
OH0486603Medicare ID - Type Unspecified
OH341572119 00OtherBUC
B96523Medicare UPIN
OH0732640001Medicare NSC