Provider Demographics
NPI:1366837718
Name:MITCHELL, KEVIN (MBBS)
Entity Type:Individual
Prefix:DR
First Name:KEVIN
Middle Name:
Last Name:MITCHELL
Suffix:
Gender:M
Credentials:MBBS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3525 E LOUISE DR STE 195
Mailing Address - Street 2:
Mailing Address - City:MERIDIAN
Mailing Address - State:ID
Mailing Address - Zip Code:83642-6303
Mailing Address - Country:US
Mailing Address - Phone:208-846-8335
Mailing Address - Fax:
Practice Address - Street 1:3525 E LOUISE DR STE 195
Practice Address - Street 2:
Practice Address - City:MERIDIAN
Practice Address - State:ID
Practice Address - Zip Code:83642-6303
Practice Address - Country:US
Practice Address - Phone:208-846-8335
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-04-02
Last Update Date:2021-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDM-16029207RN0300X
MTMED-RES-LIC-42283207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Yes207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrology