Provider Demographics
NPI:1184624934
Name:MASYK, TATIANA (MD)
Entity type:Individual
Prefix:
First Name:TATIANA
Middle Name:
Last Name:MASYK
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5705 SUN VALLEY BLVD
Mailing Address - Street 2:
Mailing Address - City:SYLVANIA
Mailing Address - State:OH
Mailing Address - Zip Code:43560-3745
Mailing Address - Country:US
Mailing Address - Phone:517-403-6857
Mailing Address - Fax:
Practice Address - Street 1:6480 ROCKSIDE WOODS BLVD S STE 330
Practice Address - Street 2:
Practice Address - City:INDEPENDENCE
Practice Address - State:OH
Practice Address - Zip Code:44131-2222
Practice Address - Country:US
Practice Address - Phone:567-316-6755
Practice Address - Fax:216-238-9526
Is Sole Proprietor?:No
Enumeration Date:2005-07-22
Last Update Date:2023-08-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35.072419207Q00000X
MI4301069338207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2722265Medicaid
MI4917088Medicaid
6088OtherHPM
MI0804610531OtherBCBS
MI03605OtherPARAMOUNT
117183OtherGLHP
MI117183OtherCARE CHOICES
5418586OtherAETNA
P00343617OtherRRMC
000000491867OtherANTHEM
MI4623463Medicaid
MI4623463Medicaid
MI4917088Medicaid
OH2722265Medicaid
P00710646Medicare PIN
G47976Medicare UPIN
P00343617OtherRRMC
MI0N90980Medicare ID - Type UnspecifiedMEDICARE PROVIDER ID