Provider Demographics
NPI:1992793780
Name:WASYLENKO, MARK JAMES (MD)
Entity type:Individual
Prefix:DR
First Name:MARK
Middle Name:JAMES
Last Name:WASYLENKO
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:115 BRUSHY CREEK RD
Mailing Address - Street 2:
Mailing Address - City:EASLEY
Mailing Address - State:SC
Mailing Address - Zip Code:29642-1120
Mailing Address - Country:US
Mailing Address - Phone:864-855-1633
Mailing Address - Fax:864-855-1323
Practice Address - Street 1:115 BRUSHY CREEK RD
Practice Address - Street 2:
Practice Address - City:EASLEY
Practice Address - State:SC
Practice Address - Zip Code:29642-1120
Practice Address - Country:US
Practice Address - Phone:864-855-1633
Practice Address - Fax:864-855-1323
Is Sole Proprietor?:No
Enumeration Date:2005-10-06
Last Update Date:2011-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC278069Medicaid
F504606089Medicare ID - Type Unspecified
SC278069Medicaid