Healthcare Provider Details

I. General information

NPI: 1588059471
Provider Name (Legal Business Name): WASSIM MALAK M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/30/2015
Last Update Date: 03/26/2021
Certification Date: 03/26/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

820 HARRISON AVE BLDG 3
BOSTON MA
02118-2905
US

IV. Provider business mailing address

525 E MARKET ST
AKRON OH
44304-1619
US

V. Phone/Fax

Practice location:
  • Phone: 617-638-6610
  • Fax:
Mailing address:
  • Phone: 330-375-3043
  • Fax: 330-706-4856

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number267962
License Number StateMA
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number267962
License Number StateMA
# 3
Primary TaxonomyY
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number35141674
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: