Healthcare Provider Details

I. General information

NPI: 1487963807
Provider Name (Legal Business Name): MARK KWAME OPPONG RN
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/04/2010
Last Update Date: 04/30/2026
Certification Date: 04/30/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

167 MACENROE DR
BLACKLICK OH
43004-9339
US

IV. Provider business mailing address

642 THERON DR
PICKERINGTON OH
43147-2071
US

V. Phone/Fax

Practice location:
  • Phone: 614-256-9209
  • Fax:
Mailing address:
  • Phone: 614-256-9209
  • Fax: 614-577-0767

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License NumberRN-359435
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: