Basic Information
Provider Information | |||||||||
NPI: | 1417924168 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | MAK | ||||||||
FirstName: | JOHN | ||||||||
MiddleName: |   | ||||||||
NamePrefix: | DR. | ||||||||
NameSuffix: |   | ||||||||
Credential: | M.D. | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 11350 MCCORMICK RD | ||||||||
Address2: | EXECUTIVE PLAZA 1, STE. 501 | ||||||||
City: | HUNT VALLEY | ||||||||
State: | MD | ||||||||
PostalCode: | 21031 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4103291071 | ||||||||
FaxNumber: | 4103291054 | ||||||||
Practice Location | |||||||||
Address1: | 55 SCHANCK RD | ||||||||
Address2: | SUTE 8A | ||||||||
City: | FREEHOLD | ||||||||
State: | NJ | ||||||||
PostalCode: | 07728 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7324319544 | ||||||||
FaxNumber: | 7324319313 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 03/01/2006 | ||||||||
LastUpdateDate: | 06/18/2021 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | Y | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 06/18/2021 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207L00000X | 25MA08226700 | NJ | N |   | Allopathic & Osteopathic Physicians | Anesthesiology |   | 207LP2900X | 25MA08226700 | NJ | N |   | Allopathic & Osteopathic Physicians | Anesthesiology | Pain Medicine | 208VP0014X | 25MA08226700 | NJ | Y |   | Allopathic & Osteopathic Physicians | Pain Medicine | Interventional Pain Medicine |
ID Information
ID | Type | State | Issuer | Description | 112407SL4 | 01 | NJ | MEDICARE INDIVIDUAL ID NUMBER | OTHER |