Provider Demographics
NPI:1003833633
Name:MITCHELL, MARK ANTHONY (DO, FACOEP-D FACEP)
Entity Type:Individual
Prefix:DR
First Name:MARK
Middle Name:ANTHONY
Last Name:MITCHELL
Suffix:
Gender:M
Credentials:DO, FACOEP-D FACEP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1648 W DIVISION ST UNIT 703
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60622-3927
Mailing Address - Country:US
Mailing Address - Phone:312-369-9727
Mailing Address - Fax:
Practice Address - Street 1:401 FAIRWAY DR STE 200
Practice Address - Street 2:
Practice Address - City:DEERFIELD BEACH
Practice Address - State:FL
Practice Address - Zip Code:33441-1800
Practice Address - Country:US
Practice Address - Phone:561-208-1970
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-17
Last Update Date:2023-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXN5251207P00000X, 207R00000X
OH34.010137207P00000X, 207R00000X
IL036084550207P00000X, 207R00000X
WI44861-21207P00000X, 207R00000X
MS13723207P00000X, 207R00000X
LADO.000259207R00000X
OK7157207R00000X
IADO-04144207R00000X
FLOD14965207R00000X
FLOS14965207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL02281810Medicaid
IL036084550Medicaid
WI43502100Medicaid
E97193Medicare UPIN
WI43502100Medicaid
IL036084550Medicaid