1669651618 NPI number — ALBERT C MAK MD INC

Table of content: (NPI 1669651618)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1669651618 NPI number — ALBERT C MAK MD INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
ALBERT C MAK MD INC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1669651618
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/24/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 80520
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SAN MARINO
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
91118-8520
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
805-577-8730
Provider Business Mailing Address Fax Number:
805-991-4065

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
707 S GARFIELD AVE
Provider Second Line Business Practice Location Address:
BSMT
Provider Business Practice Location Address City Name:
ALHAMBRA
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
91801-5859
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
805-577-8730
Provider Business Practice Location Address Fax Number:
805-991-4065
Provider Enumeration Date:
10/26/2007

Additional Information

Authorized Official

Authorized Official Last Name:
RIVERA
Authorized Official First Name:
ROSE MARIE
Authorized Official Middle Name:
Authorized Official Title or Position:
ADMINISTRATOR
Authorized Official Telephone Number:
805-577-8730

Provider Taxonomy Codes

  • Taxonomy code: 2085R0001X , with the licence number:  G79330 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 00G793300 , issued by the state of ( CA ) . This identifiers is of the category "MEDICAID".




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