Provider Demographics
NPI:1235357252
Name:MITCHELL, JESSE DAVID (MD)
Entity Type:Individual
Prefix:MR
First Name:JESSE
Middle Name:DAVID
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 1:400 NEWPORT CENTER DR
Mailing Address - Street 2:SUITE 210
Mailing Address - City:NEWPORT BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:92660-7601
Mailing Address - Country:US
Mailing Address - Phone:949-720-9500
Mailing Address - Fax:
Practice Address - Street 1:400 NEWPORT CENTER DR
Practice Address - Street 2:SUITE 210
Practice Address - City:NEWPORT BEACH
Practice Address - State:CA
Practice Address - Zip Code:92660-7601
Practice Address - Country:US
Practice Address - Phone:949-720-9500
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-23
Last Update Date:2016-07-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAC43311207N00000X
CACO43311261QM2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
Not Answered261QM2500XAmbulatory Health Care FacilitiesClinic/CenterMedical Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CACO43311OtherMEDICAL LICENSE