Provider Demographics
NPI:1306406269
Name:MITCHELL, IDELL MARIE (OD)
Entity Type:Individual
Prefix:DR
First Name:IDELL
Middle Name:MARIE
Last Name:MITCHELL
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:NATCHITOCHES FAMILY EYE CARE LLC
Mailing Address - Street 2:946 KEYSER AVENUE
Mailing Address - City:NATCHITOCHES
Mailing Address - State:LA
Mailing Address - Zip Code:71457
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:946 KEYSER AVE
Practice Address - Street 2:
Practice Address - City:NATCHITOCHES
Practice Address - State:LA
Practice Address - Zip Code:71457-6266
Practice Address - Country:US
Practice Address - Phone:318-357-8194
Practice Address - Fax:318-352-3145
Is Sole Proprietor?:Yes
Enumeration Date:2019-06-13
Last Update Date:2021-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X, 390200000X
LA1901-837AT152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training ProgramGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA2535854Medicaid