Healthcare Provider Details

I. General information

NPI: 1184624934
Provider Name (Legal Business Name): TATIANA MASYK MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/22/2005
Last Update Date: 08/04/2023
Certification Date: 08/04/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6480 ROCKSIDE WOODS BLVD S STE 330
INDEPENDENCE OH
44131-2222
US

IV. Provider business mailing address

5705 SUN VALLEY BLVD
SYLVANIA OH
43560-3745
US

V. Phone/Fax

Practice location:
  • Phone: 567-316-6755
  • Fax: 216-238-9526
Mailing address:
  • Phone: 517-403-6857
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number35.072419
License Number StateOH
# 2
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number4301069338
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: