Provider Demographics
NPI:1326087461
Name:MITCHUM, MARK CHANDLER (OD)
Entity Type:Individual
Prefix:DR
First Name:MARK
Middle Name:CHANDLER
Last Name:MITCHUM
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:428 CHANDLER GRANT DR
Mailing Address - Street 2:
Mailing Address - City:CARY
Mailing Address - State:NC
Mailing Address - Zip Code:27519-8838
Mailing Address - Country:US
Mailing Address - Phone:336-524-6604
Mailing Address - Fax:336-524-6579
Practice Address - Street 1:2648 LEE AVENUE
Practice Address - Street 2:
Practice Address - City:SANFORD
Practice Address - State:NC
Practice Address - Zip Code:27332-5950
Practice Address - Country:US
Practice Address - Phone:919-775-5221
Practice Address - Fax:919-775-7655
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-05
Last Update Date:2019-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC1270152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC89093N1Medicaid
NC093N1OtherBCBSNC
NC89093N1Medicaid
NC093N1OtherBCBSNC