Provider Demographics
NPI:1245229970
Name:MITCHELL, BRUCE LEROY (MD)
Entity Type:Individual
Prefix:DR
First Name:BRUCE
Middle Name:LEROY
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 1:550 PEACHTREE ST NE
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30308-2208
Mailing Address - Country:US
Mailing Address - Phone:404-686-6730
Mailing Address - Fax:
Practice Address - Street 1:550 PEACHTREE ST NE
Practice Address - Street 2:
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30308-2208
Practice Address - Country:US
Practice Address - Phone:404-686-6730
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-10-15
Last Update Date:2015-09-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME70743207R00000X
GA031292208M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208M00000XAllopathic & Osteopathic PhysiciansHospitalist
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
DC32760OtherBLUECROSS/BLUESHIELD
FL110145938OtherRAILROAD MEDICARE
FL268585000Medicaid
FLE09596Medicare UPIN
FL32760Medicare ID - Type Unspecified