Provider Demographics
NPI:1629059811
Name:MITCHELL, DOUGLAS C (MD)
Entity Type:Individual
Prefix:
First Name:DOUGLAS
Middle Name:C
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 1:2211 LOMAS BLVD NE
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87106-2719
Mailing Address - Country:US
Mailing Address - Phone:505-272-3119
Mailing Address - Fax:
Practice Address - Street 1:2211 LOMAS BLVD NE
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87106-2719
Practice Address - Country:US
Practice Address - Phone:505-272-3119
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-11-07
Last Update Date:2023-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO39134207L00000X
NMMD2020-0581207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO56282371Medicaid
COC810932Medicare PIN
CO56282371Medicaid