Provider Demographics
NPI:1710108402
Name:MARK G. MITCHELL, OD, LTD.
Entity Type:Organization
Organization Name:MARK G. MITCHELL, OD, LTD.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:MARK
Authorized Official - Middle Name:GLENN
Authorized Official - Last Name:MITCHELL
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:775-825-0506
Mailing Address - Street 1:4600 KIETZKE LN
Mailing Address - Street 2:B-119
Mailing Address - City:RENO
Mailing Address - State:NV
Mailing Address - Zip Code:89502-5033
Mailing Address - Country:US
Mailing Address - Phone:775-825-0506
Mailing Address - Fax:775-825-0873
Practice Address - Street 1:4600 KIETZKE LN
Practice Address - Street 2:B-119
Practice Address - City:RENO
Practice Address - State:NV
Practice Address - Zip Code:89502-5033
Practice Address - Country:US
Practice Address - Phone:775-825-0506
Practice Address - Fax:775-825-0873
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-01
Last Update Date:2013-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV374152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
V28949OtherPTAN
V28949OtherPTAN