1982998100 NPI number — MARK LESLIE WITKOWSKI DO

Table of content: MARK LESLIE WITKOWSKI DO (NPI 1982998100)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1982998100 NPI number — MARK LESLIE WITKOWSKI DO

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
WITKOWSKI
Provider First Name:
MARK
Provider Middle Name:
LESLIE
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
DO
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1982998100
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
04/03/2025
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 421718
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
GEORGETOWN
Provider Business Mailing Address State Name:
SC
Provider Business Mailing Address Postal Code:
29442-4203
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
843-527-7000
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4040 HIGHWAY 17
Provider Second Line Business Practice Location Address:
SUITE 202
Provider Business Practice Location Address City Name:
MURRELLS INLET
Provider Business Practice Location Address State Name:
SC
Provider Business Practice Location Address Postal Code:
29576-5098
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
843-652-8390
Provider Business Practice Location Address Fax Number:
843-652-8391
Provider Enumeration Date:
06/06/2011

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 208600000X , with the licence number:  R9182 , registered in the state of IA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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