Provider Demographics
NPI:1699720821
Name:MATAOSKY, MARK A (MD)
Entity type:Individual
Prefix:DR
First Name:MARK
Middle Name:A
Last Name:MATAOSKY
Suffix:
Gender:M
Credentials:MD
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Mailing Address - Street 1:3601 LADSON RD STE 100
Mailing Address - Street 2:
Mailing Address - City:LADSON
Mailing Address - State:SC
Mailing Address - Zip Code:29456-4304
Mailing Address - Country:US
Mailing Address - Phone:843-285-2500
Mailing Address - Fax:843-285-2505
Practice Address - Street 1:3601 LADSON RD STE 100
Practice Address - Street 2:
Practice Address - City:LADSON
Practice Address - State:SC
Practice Address - Zip Code:29456-4304
Practice Address - Country:US
Practice Address - Phone:843-797-7700
Practice Address - Fax:843-797-1271
Is Sole Proprietor?:No
Enumeration Date:2006-05-24
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
SC26990207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCPA4833Medicaid
SC26990OtherLICENSE #
SCBM7669887OtherDEA #
SCPA4833Medicaid
SCBM7669887OtherDEA #