Provider Demographics
NPI:1114123643
Name:MITCHELL, CARTER WALLACE (MD)
Entity Type:Individual
Prefix:DR
First Name:CARTER
Middle Name:WALLACE
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:PO BOX 418283
Mailing Address - Street 2:
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02241-8283
Mailing Address - Country:US
Mailing Address - Phone:703-558-1544
Mailing Address - Fax:
Practice Address - Street 1:18109 PRINCE PHILIP DR
Practice Address - Street 2:SUITE 325
Practice Address - City:OLNEY
Practice Address - State:MD
Practice Address - Zip Code:20832-1519
Practice Address - Country:US
Practice Address - Phone:301-774-8958
Practice Address - Fax:301-774-8959
Is Sole Proprietor?:Yes
Enumeration Date:2007-06-22
Last Update Date:2012-03-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD0067371207XX0005X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207XX0005XAllopathic & Osteopathic PhysiciansOrthopaedic SurgerySports Medicine