Provider Demographics
NPI:1346263159
Name:MITCHELL, CHARLES KENNETH (MD)
Entity Type:Individual
Prefix:DR
First Name:CHARLES
Middle Name:KENNETH
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:PO BOX 751649
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28275-1649
Mailing Address - Country:US
Mailing Address - Phone:843-789-1620
Mailing Address - Fax:843-724-2440
Practice Address - Street 1:3508 S LIVE OAK DR STE 100
Practice Address - Street 2:
Practice Address - City:MONCKS CORNER
Practice Address - State:SC
Practice Address - Zip Code:29461-8737
Practice Address - Country:US
Practice Address - Phone:843-606-7996
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-25
Last Update Date:2022-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC33289208600000X, 208600000X
SCTL33289208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCN00360Medicaid
SCN00360Medicaid
NC2240994Medicare ID - Type Unspecified
SCN00360Medicaid
SCAA64099223Medicare PIN