Provider Demographics
NPI:1518027630
Name:MITCHELL, S TODD (MD)
Entity Type:Individual
Prefix:
First Name:S
Middle Name:TODD
Last Name:MITCHELL
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 1:445 SUMMIT ROAD
Mailing Address - Street 2:
Mailing Address - City:WATSONVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:95076
Mailing Address - Country:US
Mailing Address - Phone:831-479-7916
Mailing Address - Fax:
Practice Address - Street 1:445 SUMMIT ROAD
Practice Address - Street 2:
Practice Address - City:WATSONVILLE
Practice Address - State:CA
Practice Address - Zip Code:95076
Practice Address - Country:US
Practice Address - Phone:831-479-7916
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-12-11
Last Update Date:2013-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG59020207Q00000X, 207QG0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207QG0300XAllopathic & Osteopathic PhysiciansFamily MedicineGeriatric Medicine
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA080051612OtherRR MEDICARE
CA00G590200Medicaid
CA00G590200Medicare ID - Type Unspecified
CA00G590200Medicaid