Provider Demographics
NPI:1073549226
Name:MAYO, MITCHELL J (BCO)
Entity Type:Individual
Prefix:
First Name:MITCHELL
Middle Name:J
Last Name:MAYO
Suffix:
Gender:M
Credentials:BCO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2155 HOLLOW BROOK DR
Mailing Address - Street 2:STE 40
Mailing Address - City:COLORADO SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:80918-1451
Mailing Address - Country:US
Mailing Address - Phone:719-272-6416
Mailing Address - Fax:719-272-6408
Practice Address - Street 1:2155 HOLLOW BROOK DR
Practice Address - Street 2:STE 40
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80918-1451
Practice Address - Country:US
Practice Address - Phone:719-272-6416
Practice Address - Fax:719-272-6408
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-22
Last Update Date:2020-02-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156FX1700XEye and Vision Services ProvidersTechnician/TechnologistOcularist
Provider Identifiers
StateIdentifier IDID TypeIssuer
364478259OtherTRICARE
CO07137214Medicaid
364478259OtherTRICARE