Provider Demographics
NPI:1417955766
Name:PRESTON, MITCHELL CRAIG (MD)
Entity Type:Individual
Prefix:
First Name:MITCHELL
Middle Name:CRAIG
Last Name:PRESTON
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 1:613 N 2ND ST
Mailing Address - Street 2:
Mailing Address - City:ROGERS
Mailing Address - State:AR
Mailing Address - Zip Code:72756-6611
Mailing Address - Country:US
Mailing Address - Phone:479-878-1060
Mailing Address - Fax:479-878-1070
Practice Address - Street 1:613 N 2ND ST
Practice Address - Street 2:
Practice Address - City:ROGERS
Practice Address - State:AR
Practice Address - Zip Code:72756
Practice Address - Country:US
Practice Address - Phone:479-878-1060
Practice Address - Fax:479-878-1070
Is Sole Proprietor?:No
Enumeration Date:2005-07-11
Last Update Date:2023-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK19524207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ821753Medicaid
AZZ78560Medicare ID - Type Unspecified
AZ821753Medicaid