Provider Demographics
NPI:1245612969
Name:STOTLAND, MITCHELL (MD)
Entity Type:Individual
Prefix:
First Name:MITCHELL
Middle Name:
Last Name:STOTLAND
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 1:2885 SANFORD AVE SW STE 46566
Mailing Address - Street 2:
Mailing Address - City:GRANDVILLE
Mailing Address - State:MI
Mailing Address - Zip Code:49418-1342
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2885 SANFORD AVE SW
Practice Address - Street 2:UNIT 46566
Practice Address - City:GRANDVILLE
Practice Address - State:MI
Practice Address - Zip Code:49418-1342
Practice Address - Country:US
Practice Address - Phone:616-730-1838
Practice Address - Fax:800-988-9999
Is Sole Proprietor?:Yes
Enumeration Date:2015-06-19
Last Update Date:2020-06-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01078523A2083X0100X
390200000X
WV28795208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
No2083X0100XAllopathic & Osteopathic PhysiciansPreventive MedicineOccupational Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC252874OtherNC
AL38550OtherLICENSE
GA83897OtherGEORGIA
AZ59141OtherLICENSE
FLME141497OtherFLORIDA