Provider Demographics
NPI:1508831918
Name:MITCHELL, CHARLOTTE (MD)
Entity Type:Individual
Prefix:
First Name:CHARLOTTE
Middle Name:
Last Name:MITCHELL
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:30 E 15TH ST
Mailing Address - Street 2:SUITE 310
Mailing Address - City:CHICAGO HEIGHTS
Mailing Address - State:IL
Mailing Address - Zip Code:60411-3459
Mailing Address - Country:US
Mailing Address - Phone:708-754-3225
Mailing Address - Fax:708-754-3288
Practice Address - Street 1:30 E 15TH ST
Practice Address - Street 2:SUITE 310
Practice Address - City:CHICAGO HEIGHTS
Practice Address - State:IL
Practice Address - Zip Code:60411-3459
Practice Address - Country:US
Practice Address - Phone:708-754-3225
Practice Address - Fax:708-754-3288
Is Sole Proprietor?:Yes
Enumeration Date:2006-02-20
Last Update Date:2008-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILK48389Medicare PIN