Healthcare Provider Details

I. General information

NPI: 1174978605
Provider Name (Legal Business Name): MATTHEW WILLIAM MUBARAK M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/03/2016
Last Update Date: 02/20/2023
Certification Date: 02/20/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2113 ADAMS GRV STE 101
COLUMBIA SC
29203-6957
US

IV. Provider business mailing address

7901 FARROW RD
COLUMBIA SC
29203-3220
US

V. Phone/Fax

Practice location:
  • Phone: 803-256-0531
  • Fax: 803-765-9052
Mailing address:
  • Phone: 803-256-0531
  • Fax: 803-765-9052

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number82385
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: