Provider Demographics
NPI:1710097019
Name:MITCHELL, CONNIE L (MD)
Entity Type:Individual
Prefix:MS
First Name:CONNIE
Middle Name:L
Last Name:MITCHELL
Suffix:
Gender:F
Credentials:MD
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Mailing Address - Street 1:5525 GREENWAY ST
Mailing Address - Street 2:UNIT B-2
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48204-2112
Mailing Address - Country:US
Mailing Address - Phone:313-701-1187
Mailing Address - Fax:313-931-9113
Practice Address - Street 1:5525 GREENWAY ST
Practice Address - Street 2:UNIT B-2
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48204-2112
Practice Address - Country:US
Practice Address - Phone:313-701-1187
Practice Address - Fax:313-931-9113
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-30
Last Update Date:2011-02-08
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
MIM4301056553207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4706980Medicaid
F88563Medicare UPIN