Provider Demographics
NPI:1417998006
Name:MITCHELL, BRIAN K (O D)
Entity Type:Individual
Prefix:DR
First Name:BRIAN
Middle Name:K
Last Name:MITCHELL
Suffix:
Gender:M
Credentials:O D
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:935 ROYAL AVE
Mailing Address - Street 2:
Mailing Address - City:MEDFORD
Mailing Address - State:OR
Mailing Address - Zip Code:97504-6140
Mailing Address - Country:US
Mailing Address - Phone:541-779-2211
Mailing Address - Fax:541-779-8778
Practice Address - Street 1:935 ROYAL AVE
Practice Address - Street 2:
Practice Address - City:MEDFORD
Practice Address - State:OR
Practice Address - Zip Code:97504-6140
Practice Address - Country:US
Practice Address - Phone:541-779-2211
Practice Address - Fax:541-779-8778
Is Sole Proprietor?:No
Enumeration Date:2006-06-08
Last Update Date:2011-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR3079ATI152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR064886Medicaid
ORR115635Medicare PIN
OR064886Medicaid