Healthcare Provider Details

I. General information

NPI: 1982999504
Provider Name (Legal Business Name): MARK BREW
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/11/2011
Last Update Date: 07/20/2022
Certification Date: 07/20/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3120 MIDLAND VALLEY ST
NORMAN OK
73069-6970
US

IV. Provider business mailing address

5520 MESA RIDGE LN
COLUMBUS OH
43231-6731
US

V. Phone/Fax

Practice location:
  • Phone: 614-943-1041
  • Fax:
Mailing address:
  • Phone: 614-625-6486
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number209311
License Number StateOK
# 2
Primary TaxonomyN
Taxonomy Code164W00000X
TaxonomyLicensed Practical Nurse
License NumberPN.133673-M-IV
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: