Provider Demographics
NPI:1386684405
Name:MITCHELL, JONATHAN CHRISTOPHER (MD)
Entity Type:Individual
Prefix:
First Name:JONATHAN
Middle Name:CHRISTOPHER
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 40
Mailing Address - Street 2:
Mailing Address - City:PUYALLUP
Mailing Address - State:WA
Mailing Address - Zip Code:98371-0137
Mailing Address - Country:US
Mailing Address - Phone:253-697-5502
Mailing Address - Fax:253-697-5510
Practice Address - Street 1:11102 SUNRISE BLVD E
Practice Address - Street 2:SUITE 110
Practice Address - City:PUYALLUP
Practice Address - State:WA
Practice Address - Zip Code:98374-8846
Practice Address - Country:US
Practice Address - Phone:253-697-7350
Practice Address - Fax:253-841-5962
Is Sole Proprietor?:No
Enumeration Date:2006-06-07
Last Update Date:2011-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD00041368207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA0141390OtherL & I PROVIDER NUMBER
WA1121MIOtherREGENCE RIDER NUMBER
WA7699536OtherAETNA PROVIDER NUMBER
WA8316432Medicaid
WA911203494BXOtherKPS PROVIDER NUMBER
WA98375E004OtherTRICARE PROVIDER NUMBER
WA8316432Medicaid