Healthcare Provider Details

I. General information

NPI: 1568415669
Provider Name (Legal Business Name): LINDA L. MAK M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/18/2006
Last Update Date: 10/15/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1703 ROSS AVE #212
EL CENTRO CA
92243
US

IV. Provider business mailing address

PO BOX 5100
LA QUINTA CA
92248-5100
US

V. Phone/Fax

Practice location:
  • Phone: 760-568-0209
  • Fax: 760-568-0184
Mailing address:
  • Phone: 760-568-0209
  • Fax: 760-568-0184

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207ND0101X
TaxonomyMOHS-Micrographic Surgery Physician
License NumberA51014
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code207NS0135X
TaxonomyProcedural Dermatology Physician
License NumberA51014
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: