Provider Demographics
NPI:1508850694
Name:MITCHELL, IDOL RAY (DPM)
Entity Type:Individual
Prefix:
First Name:IDOL
Middle Name:RAY
Last Name:MITCHELL
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:437 EAST GRANT STREET
Mailing Address - Street 2:
Mailing Address - City:MACOMB
Mailing Address - State:IL
Mailing Address - Zip Code:61455-3352
Mailing Address - Country:US
Mailing Address - Phone:309-837-3964
Mailing Address - Fax:309-837-3966
Practice Address - Street 1:437 EAST GRANT STREET
Practice Address - Street 2:
Practice Address - City:MACOMB
Practice Address - State:IL
Practice Address - Zip Code:61455-3352
Practice Address - Country:US
Practice Address - Phone:309-837-3964
Practice Address - Fax:309-837-3966
Is Sole Proprietor?:Yes
Enumeration Date:2005-09-06
Last Update Date:2008-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL016-004683213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
4452210001OtherDMERC
480034728OtherRAILROAD MEDICARE PROV #
IL016004683Medicaid
IL214428OtherMEDICARE ID
4452210001OtherDMERC
IL4452210001Medicare NSC
ILK33206Medicare PIN
IL016004683Medicaid