Provider Demographics
NPI:1164422127
Name:MITCHELL, EDMUND M I (MD)
Entity Type:Individual
Prefix:
First Name:EDMUND
Middle Name:M
Last Name:MITCHELL
Suffix:I
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 1:2035 MESQUITE AVE
Mailing Address - Street 2:
Mailing Address - City:LAKE HAVASU CITY
Mailing Address - State:AZ
Mailing Address - Zip Code:86403-5894
Mailing Address - Country:US
Mailing Address - Phone:928-453-1101
Mailing Address - Fax:928-453-1171
Practice Address - Street 1:2035 MESQUITE AVENUE
Practice Address - Street 2:
Practice Address - City:LAKE HAVASU CITY
Practice Address - State:AZ
Practice Address - Zip Code:86403-5894
Practice Address - Country:US
Practice Address - Phone:928-453-1101
Practice Address - Fax:928-453-1171
Is Sole Proprietor?:Yes
Enumeration Date:2005-07-29
Last Update Date:2011-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ43534207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
F64050Medicare UPIN
0844551Medicare ID - Type Unspecified