Provider Demographics
NPI:1043212343
Name:MITCHELL, RONNIE (D O)
Entity Type:Individual
Prefix:DR
First Name:RONNIE
Middle Name:
Last Name:MITCHELL
Suffix:
Gender:M
Credentials:D O
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:751 E SOUTHLAKE BLVD STE 100
Mailing Address - Street 2:
Mailing Address - City:SOUTHLAKE
Mailing Address - State:TX
Mailing Address - Zip Code:76092-6352
Mailing Address - Country:US
Mailing Address - Phone:972-355-3771
Mailing Address - Fax:972-739-2418
Practice Address - Street 1:751 E SOUTHLAKE BLVD STE 100
Practice Address - Street 2:
Practice Address - City:SOUTHLAKE
Practice Address - State:TX
Practice Address - Zip Code:76092-6352
Practice Address - Country:US
Practice Address - Phone:972-355-3771
Practice Address - Fax:972-739-2418
Is Sole Proprietor?:No
Enumeration Date:2005-06-01
Last Update Date:2019-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXK1566207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX096696204Medicaid
TX096696204Medicaid
TX340518YKP5Medicare PIN
TX8F6109Medicare PIN