Provider Demographics
NPI:1134124308
Name:MITCHELL, MARK GLENN (OD)
Entity Type:Individual
Prefix:DR
First Name:MARK
Middle Name:GLENN
Last Name:MITCHELL
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2425 GOLDEN HILL
Mailing Address - Street 2:STE 106-205
Mailing Address - City:PASO ROBLES
Mailing Address - State:CA
Mailing Address - Zip Code:93446
Mailing Address - Country:US
Mailing Address - Phone:775-848-8214
Mailing Address - Fax:
Practice Address - Street 1:678 E SANTA CLARA ST
Practice Address - Street 2:
Practice Address - City:SAN JOSE
Practice Address - State:CA
Practice Address - Zip Code:95112-1931
Practice Address - Country:US
Practice Address - Phone:408-293-2020
Practice Address - Fax:408-271-0225
Is Sole Proprietor?:Yes
Enumeration Date:2005-06-15
Last Update Date:2017-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA8285T152W00000X
NV374152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CASD0082850Medicaid
NVP00122561OtherRETIRED RAILROAD MEDICARE
NVP00122561OtherRETIRED RAILROAD MEDICARE
CASD0082850Medicaid
NV38951Medicare PIN
CAP00122561Medicare PIN
CAP00122561Medicare PIN