Healthcare Provider Details

I. General information

NPI: 1316991961
Provider Name (Legal Business Name): PHILIP F MUBARAK MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/19/2006
Last Update Date: 05/21/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2113 ADAMS GRV SUITE 101
COLUMBIA SC
29203-7102
US

IV. Provider business mailing address

2113 ADAMS GRV SUITE 101
COLUMBIA SC
29203-7102
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 Number12782
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: