Provider Demographics
NPI:1013027200
Name:MITCHELL, DAVID R (MD)
Entity Type:Individual
Prefix:
First Name:DAVID
Middle Name:R
Last Name:MITCHELL
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 1:5970 CHURCHVIEW DR
Mailing Address - Street 2:
Mailing Address - City:ROCKFORD
Mailing Address - State:IL
Mailing Address - Zip Code:61107-2574
Mailing Address - Country:US
Mailing Address - Phone:815-971-2000
Mailing Address - Fax:
Practice Address - Street 1:5970 CHURCHVIEW DR
Practice Address - Street 2:
Practice Address - City:ROCKFORD
Practice Address - State:IL
Practice Address - Zip Code:61107-2574
Practice Address - Country:US
Practice Address - Phone:815-971-2000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-30
Last Update Date:2010-01-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036-070476207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036070476Medicaid
ILD15803Medicare UPIN
IL036070476Medicaid