Provider Demographics
NPI:1669414819
Name:MIKELL, OSWALD LIGHTSEY (MD)
Entity type:Individual
Prefix:DR
First Name:OSWALD
Middle Name:LIGHTSEY
Last Name:MIKELL
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:P.O. BOX 3821
Mailing Address - Street 2:
Mailing Address - City:BLUFFTON
Mailing Address - State:SC
Mailing Address - Zip Code:29910-3821
Mailing Address - Country:US
Mailing Address - Phone:843-705-0840
Mailing Address - Fax:843-705-0890
Practice Address - Street 1:3901 MAIN STE D
Practice Address - Street 2:
Practice Address - City:HILTON HEAD ISLAND
Practice Address - State:SC
Practice Address - Zip Code:29926
Practice Address - Country:US
Practice Address - Phone:843-689-5259
Practice Address - Fax:843-689-3797
Is Sole Proprietor?:No
Enumeration Date:2006-06-12
Last Update Date:2016-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC11219207N00000X, 207ND0101X, 207NS0135X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ND0101XAllopathic & Osteopathic PhysiciansDermatologyMOHS-Micrographic Surgery
No207N00000XAllopathic & Osteopathic PhysiciansDermatology
No207NS0135XAllopathic & Osteopathic PhysiciansDermatologyProcedural Dermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC112194Medicaid
SCB923164053Medicare ID - Type Unspecified
SC112194Medicaid