Provider Demographics
NPI:1144390873
Name:MITCHELL, KENNETH DERNELL (DPM)
Entity Type:Individual
Prefix:DR
First Name:KENNETH
Middle Name:DERNELL
Last Name:MITCHELL
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Mailing Address - Street 1:23999 NORTHWESTERN HWY
Mailing Address - Street 2:SUITE 220A
Mailing Address - City:SOUTHFIELD
Mailing Address - State:MI
Mailing Address - Zip Code:48075-2578
Mailing Address - Country:US
Mailing Address - Phone:248-996-6465
Mailing Address - Fax:248-996-6469
Practice Address - Street 1:23999 NORTHWESTERN HWY
Practice Address - Street 2:SUITE 220A
Practice Address - City:SOUTHFIELD
Practice Address - State:MI
Practice Address - Zip Code:48075-2578
Practice Address - Country:US
Practice Address - Phone:248-996-6465
Practice Address - Fax:248-996-6469
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-09
Last Update Date:2013-10-22
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MI5901001869213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist