Provider Demographics
NPI:1568461051
Name:NUTT, MITCHELL E (MD)
Entity Type:Individual
Prefix:
First Name:MITCHELL
Middle Name:E
Last Name:NUTT
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 1:200 SAINT CLAIR STREET
Mailing Address - Street 2:GRAND LAKE PHYSICIAN PRACTICES
Mailing Address - City:SAINT MARYS
Mailing Address - State:OH
Mailing Address - Zip Code:45885-2400
Mailing Address - Country:US
Mailing Address - Phone:419-394-3387
Mailing Address - Fax:419-394-7313
Practice Address - Street 1:1067 HAGER ST
Practice Address - Street 2:GRAND LAKE OB/GYN
Practice Address - City:SAINT MARYS
Practice Address - State:OH
Practice Address - Zip Code:45885-2422
Practice Address - Country:US
Practice Address - Phone:419-394-3387
Practice Address - Fax:419-394-7313
Is Sole Proprietor?:No
Enumeration Date:2005-07-18
Last Update Date:2014-01-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35.092080207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0204997Medicaid
OH9934724OtherMEDICARE GROUP PTAN LOCATION
OH1447288717OtherGROUP NPI
OHNU4097102OtherMEDICARE PTAN