Provider Demographics
NPI:1790846582
Name:ELKINGTON, MARK WAYNE (MD)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:WAYNE
Last Name:ELKINGTON
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 1:130 A ST SW
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:OK
Mailing Address - Zip Code:74354-6806
Mailing Address - Country:US
Mailing Address - Phone:918-542-1836
Mailing Address - Fax:
Practice Address - Street 1:130 A ST SW
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:OK
Practice Address - Zip Code:74354-6806
Practice Address - Country:US
Practice Address - Phone:918-542-1836
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-12-13
Last Update Date:2010-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK20887174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK100207350BMedicaid
OK100207350BMedicaid