Provider Demographics
NPI:1689634479
Name:MITCHELL, MARK EDWARD (MD)
Entity Type:Individual
Prefix:MR
First Name:MARK
Middle Name:EDWARD
Last Name:MITCHELL
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
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Other - Credentials:
Mailing Address - Street 1:2960 TONGASS AVENUE
Mailing Address - Street 2:
Mailing Address - City:KETCHIKAN
Mailing Address - State:AK
Mailing Address - Zip Code:99901-5742
Mailing Address - Country:US
Mailing Address - Phone:907-228-4900
Mailing Address - Fax:800-852-3264
Practice Address - Street 1:2960 TONGASS AVENUE
Practice Address - Street 2:
Practice Address - City:KETCHIKAN
Practice Address - State:AK
Practice Address - Zip Code:99901-5742
Practice Address - Country:US
Practice Address - Phone:907-228-4900
Practice Address - Fax:800-852-3264
Is Sole Proprietor?:No
Enumeration Date:2006-03-24
Last Update Date:2016-07-01
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
UT2681761205207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM52588084Medicaid
CO82071365Medicaid
UTD0289Medicaid
AZ314804Medicaid
UTF72986Medicare UPIN
AZ314804Medicaid
CO82071365Medicaid