Provider Demographics
NPI:1487641312
Name:MITCHENER, JAMES SAMUEL III (MD)
Entity Type:Individual
Prefix:
First Name:JAMES
Middle Name:SAMUEL
Last Name:MITCHENER
Suffix:III
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 1:1414 FRANKLIN RD SW
Mailing Address - Street 2:
Mailing Address - City:ROANOKE
Mailing Address - State:VA
Mailing Address - Zip Code:24016-5217
Mailing Address - Country:US
Mailing Address - Phone:540-985-0116
Mailing Address - Fax:540-985-0215
Practice Address - Street 1:1414 FRANKLIN RD SW
Practice Address - Street 2:
Practice Address - City:ROANOKE
Practice Address - State:VA
Practice Address - Zip Code:24016-5217
Practice Address - Country:US
Practice Address - Phone:540-985-0116
Practice Address - Fax:540-985-0215
Is Sole Proprietor?:Yes
Enumeration Date:2005-10-05
Last Update Date:2009-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA01010348462086S0122X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2086S0122XAllopathic & Osteopathic PhysiciansSurgeryPlastic and Reconstructive Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA007340702Medicaid
VAB77614Medicare UPIN
VA240000118Medicare ID - Type Unspecified