Provider Demographics
NPI:1568737682
Name:MITCHELL, GARY (DC)
Entity Type:Individual
Prefix:
First Name:GARY
Middle Name:
Last Name:MITCHELL
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:100 EASTSIDE DR
Mailing Address - Street 2:
Mailing Address - City:GEORGETOWN
Mailing Address - State:KY
Mailing Address - Zip Code:40324-9797
Mailing Address - Country:US
Mailing Address - Phone:502-868-0097
Mailing Address - Fax:502-868-7499
Practice Address - Street 1:100 EASTSIDE DR
Practice Address - Street 2:
Practice Address - City:GEORGETOWN
Practice Address - State:KY
Practice Address - Zip Code:40324-9797
Practice Address - Country:US
Practice Address - Phone:502-868-0097
Practice Address - Fax:502-868-7499
Is Sole Proprietor?:No
Enumeration Date:2012-03-22
Last Update Date:2020-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY5314111N00000X
KY249455111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY7100313440Medicaid
KYK054530Medicare PIN
KYK208020Medicare PIN