Provider Demographics
NPI:1134652779
Name:STORAR, MITCHELL THOMAS
Entity Type:Individual
Prefix:
First Name:MITCHELL
Middle Name:THOMAS
Last Name:STORAR
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:620 JOHN PAUL JONES CIR
Mailing Address - Street 2:
Mailing Address - City:PORTSMOUTH
Mailing Address - State:VA
Mailing Address - Zip Code:23708-2197
Mailing Address - Country:US
Mailing Address - Phone:757-953-5257
Mailing Address - Fax:
Practice Address - Street 1:620 JOHN PAUL JONES CIR
Practice Address - Street 2:
Practice Address - City:PORTSMOUTH
Practice Address - State:VA
Practice Address - Zip Code:23708-2197
Practice Address - Country:US
Practice Address - Phone:757-953-5257
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-04-11
Last Update Date:2021-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
VA01022053462084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program