Provider Demographics
NPI:1093751216
Name:LIN, MITCHELL (MD)
Entity Type:Individual
Prefix:
First Name:MITCHELL
Middle Name:
Last Name:LIN
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:PO BOX 845347
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75284-5347
Mailing Address - Country:US
Mailing Address - Phone:214-645-0355
Mailing Address - Fax:
Practice Address - Street 1:5323 HARRY HINES BLVD DALLAS
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75390-0001
Practice Address - Country:US
Practice Address - Phone:214-645-0355
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-22
Last Update Date:2016-09-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXQ9964207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A796950Medicaid
CA00A796950303OtherCALOPTIMA
CA00A796950OtherBLUE SHIELD OF CA
CA050086413OtherRR MEDICARE
CAWA79695AMedicare ID - Type Unspecified
CA00A796950303OtherCALOPTIMA