Provider Demographics
NPI:1619137858
Name:MITCHELL, MARTI L (DO)
Entity Type:Individual
Prefix:
First Name:MARTI
Middle Name:L
Last Name:MITCHELL
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:700 E 3RD ST
Mailing Address - Street 2:
Mailing Address - City:THE DALLES
Mailing Address - State:OR
Mailing Address - Zip Code:97058-2508
Mailing Address - Country:US
Mailing Address - Phone:541-296-0149
Mailing Address - Fax:541-296-0229
Practice Address - Street 1:1810 E 19TH ST STE 225
Practice Address - Street 2:
Practice Address - City:THE DALLES
Practice Address - State:OR
Practice Address - Zip Code:97058-3388
Practice Address - Country:US
Practice Address - Phone:541-296-6101
Practice Address - Fax:541-296-3741
Is Sole Proprietor?:Yes
Enumeration Date:2008-06-11
Last Update Date:2012-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
ORDO158463207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program