Provider Demographics
NPI:1689651259
Name:MITCHELL, JAY PATRICK (MD)
Entity Type:Individual
Prefix:DR
First Name:JAY
Middle Name:PATRICK
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 1:4467 ASCOT CT
Mailing Address - Street 2:
Mailing Address - City:OAKLAND TOWNSHIP
Mailing Address - State:MI
Mailing Address - Zip Code:48306-4719
Mailing Address - Country:US
Mailing Address - Phone:248-340-6166
Mailing Address - Fax:
Practice Address - Street 1:2370 WALTON BLVD
Practice Address - Street 2:SUITE 3
Practice Address - City:ROCHESTER HILLS
Practice Address - State:MI
Practice Address - Zip Code:48309-1471
Practice Address - Country:US
Practice Address - Phone:248-651-8197
Practice Address - Fax:248-651-5643
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-12-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301051931174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4286748Medicaid
MI4286748Medicaid