Provider Demographics
NPI:1083830590
Name:PHILLIPS, MITCHEL E (DO)
Entity Type:Individual
Prefix:
First Name:MITCHEL
Middle Name:E
Last Name:PHILLIPS
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5970C S RAINBOW BLVD # 100
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89118-2540
Mailing Address - Country:US
Mailing Address - Phone:702-363-4000
Mailing Address - Fax:702-362-0086
Practice Address - Street 1:5970C S RAINBOW BLVD # 100
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89118-2540
Practice Address - Country:US
Practice Address - Phone:702-363-4000
Practice Address - Fax:702-362-0086
Is Sole Proprietor?:No
Enumeration Date:2007-04-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NVDO291207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NVV40394Medicare ID - Type Unspecified
NVE43597Medicare UPIN