Basic Information
Provider Information | |||||||||
NPI: | 1578945507 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | OWOLABI | ||||||||
FirstName: | MARK | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | M.D. | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 421718 | ||||||||
Address2: |   | ||||||||
City: | GEORGETOWN | ||||||||
State: | SC | ||||||||
PostalCode: | 294424203 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8436528226 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 4320 HOLMESTOWN RD | ||||||||
Address2: |   | ||||||||
City: | MYRTLE BEACH | ||||||||
State: | SC | ||||||||
PostalCode: | 295887837 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8436528440 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 06/26/2015 | ||||||||
LastUpdateDate: | 03/29/2021 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 03/29/2021 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | S0040 | TX | N |   | Allopathic & Osteopathic Physicians | Family Medicine |   | 207Q00000X | MD190064 | OR | N |   | Allopathic & Osteopathic Physicians | Family Medicine |   | 207Q00000X | MD-20031 | HI | N |   | Allopathic & Osteopathic Physicians | Family Medicine |   | 207Q00000X | 2018-01234 | NC | N |   | Allopathic & Osteopathic Physicians | Family Medicine |   | 207Q00000X | 4301119422 | MI | Y |   | Allopathic & Osteopathic Physicians | Family Medicine |   |
No ID Information.