Provider Demographics
NPI:1659404192
Name:MITCHELL, DAVID A (OD)
Entity Type:Individual
Prefix:DR
First Name:DAVID
Middle Name:A
Last Name:MITCHELL
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12 W MAIN ST
Mailing Address - Street 2:
Mailing Address - City:FORT KENT
Mailing Address - State:ME
Mailing Address - Zip Code:04743-1231
Mailing Address - Country:US
Mailing Address - Phone:207-834-3124
Mailing Address - Fax:207-834-3127
Practice Address - Street 1:12 W MAIN ST
Practice Address - Street 2:
Practice Address - City:FORT KENT
Practice Address - State:ME
Practice Address - Zip Code:04743-1231
Practice Address - Country:US
Practice Address - Phone:207-834-3124
Practice Address - Fax:207-834-3127
Is Sole Proprietor?:No
Enumeration Date:2007-03-13
Last Update Date:2008-12-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEOPT734152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ME256900099Medicaid
T31355Medicare UPIN
ME256900099Medicaid