Healthcare Provider Details

I. General information

NPI: 1669414819
Provider Name (Legal Business Name): OSWALD LIGHTSEY MIKELL M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/12/2006
Last Update Date: 08/17/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3901 MAIN STE D
HILTON HEAD ISLAND SC
29926
US

IV. Provider business mailing address

P.O. BOX 3821
BLUFFTON SC
29910-3821
US

V. Phone/Fax

Practice location:
  • Phone: 843-689-5259
  • Fax: 843-689-3797
Mailing address:
  • Phone: 843-705-0840
  • Fax: 843-705-0890

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License Number11219
License Number StateSC
# 2
Primary TaxonomyY
Taxonomy Code207ND0101X
TaxonomyMOHS-Micrographic Surgery Physician
License Number11219
License Number StateSC
# 3
Primary TaxonomyN
Taxonomy Code207NS0135X
TaxonomyProcedural Dermatology Physician
License Number11219
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: