Provider Demographics
NPI:1922036649
Name:PAK, MICHAEL (MD)
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:
Last Name:PAK
Suffix:
Gender:M
Credentials:MD
Other - Prefix:DR
Other - First Name:VLADIMIR
Other - Middle Name:M
Other - Last Name:PAK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:524 W HIGH ST
Mailing Address - Street 2:
Mailing Address - City:BRYAN
Mailing Address - State:OH
Mailing Address - Zip Code:43506-1618
Mailing Address - Country:US
Mailing Address - Phone:419-636-9800
Mailing Address - Fax:
Practice Address - Street 1:524 W HIGH ST
Practice Address - Street 2:
Practice Address - City:BRYAN
Practice Address - State:OH
Practice Address - Zip Code:43506-1618
Practice Address - Country:US
Practice Address - Phone:419-636-9800
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-29
Last Update Date:2015-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH350788372085R0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0001XAllopathic & Osteopathic PhysiciansRadiologyRadiation Oncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
G79666Medicare UPIN