Provider Demographics
NPI:1346694585
Name:MOCK, MITCHELL
Entity Type:Individual
Prefix:
First Name:MITCHELL
Middle Name:
Last Name:MOCK
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:651 COLLIERS WAY
Mailing Address - Street 2:STE 300
Mailing Address - City:WEIRTON
Mailing Address - State:WV
Mailing Address - Zip Code:26062-5058
Mailing Address - Country:US
Mailing Address - Phone:304-797-6404
Mailing Address - Fax:
Practice Address - Street 1:560 STEUBENVILLE PIKE
Practice Address - Street 2:
Practice Address - City:BURGETTSTOWN
Practice Address - State:PA
Practice Address - Zip Code:15021-8539
Practice Address - Country:US
Practice Address - Phone:304-723-6804
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-04-13
Last Update Date:2021-02-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD472808207Q00000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program