Provider Demographics
NPI:1679991475
Name:MIMS, MARK MATTHEW (MD)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:MATTHEW
Last Name:MIMS
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 1:800 STANTON L YOUNG BLVD # 1400
Mailing Address - Street 2:
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73104-5018
Mailing Address - Country:US
Mailing Address - Phone:210-241-6275
Mailing Address - Fax:
Practice Address - Street 1:825 NE 10TH ST STE 4C
Practice Address - Street 2:
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73104-5417
Practice Address - Country:US
Practice Address - Phone:405-271-1368
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-03-31
Last Update Date:2022-03-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK35702207YX0905X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207YX0905XAllopathic & Osteopathic PhysiciansOtolaryngologyOtolaryngology/Facial Plastic Surgery