Provider Demographics
NPI:1700045770
Name:MITCHELL, MIRANDA F (MD)
Entity Type:Individual
Prefix:DR
First Name:MIRANDA
Middle Name:F
Last Name:MITCHELL
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5131 ODONOVAN DR
Mailing Address - Street 2:SUITE 500
Mailing Address - City:BATON ROUGE
Mailing Address - State:LA
Mailing Address - Zip Code:70808-4782
Mailing Address - Country:US
Mailing Address - Phone:225-374-0031
Mailing Address - Fax:225-374-0120
Practice Address - Street 1:5131 ODONOVAN DR
Practice Address - Street 2:SUITE 500
Practice Address - City:BATON ROUGE
Practice Address - State:LA
Practice Address - Zip Code:70808-4782
Practice Address - Country:US
Practice Address - Phone:225-374-0031
Practice Address - Fax:225-374-0120
Is Sole Proprietor?:Yes
Enumeration Date:2008-06-05
Last Update Date:2014-04-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
LAMD.202941207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00200212Medicaid
LA1097861Medicaid
LA4Q277DX80Medicare PIN