Provider Demographics
NPI:1700046596
Name:MITZEL, JERROD CARL (MD)
Entity Type:Individual
Prefix:DR
First Name:JERROD
Middle Name:CARL
Last Name:MITZEL
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 1:2485 12TH ST SE
Mailing Address - Street 2:
Mailing Address - City:SALEM
Mailing Address - State:OR
Mailing Address - Zip Code:97302-2151
Mailing Address - Country:US
Mailing Address - Phone:503-363-8047
Mailing Address - Fax:503-363-6571
Practice Address - Street 1:2485 12TH ST SE
Practice Address - Street 2:
Practice Address - City:SALEM
Practice Address - State:OR
Practice Address - Zip Code:97302-2151
Practice Address - Country:US
Practice Address - Phone:503-363-8047
Practice Address - Fax:503-363-6571
Is Sole Proprietor?:No
Enumeration Date:2008-06-15
Last Update Date:2017-04-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH57010891207Q00000X
AZ40749207Q00000X
ORMD28732207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR276275Medicaid
OR276275Medicaid