Provider Demographics
NPI:1710938279
Name:MITCHELL, MACK (MD)
Entity Type:Individual
Prefix:
First Name:MACK
Middle Name:
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:UT SOUTHWESTERN MEDICAL CTR
Mailing Address - Street 2:5323 HARRY HINES BLVD
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75390-9030
Mailing Address - Country:US
Mailing Address - Phone:214-648-5036
Mailing Address - Fax:
Practice Address - Street 1:UT SOUTHWESTERN MEDICAL CTR
Practice Address - Street 2:5323 HARRY HINES BLVD
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75390-9030
Practice Address - Country:US
Practice Address - Phone:214-648-5036
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-05-12
Last Update Date:2011-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXN9911207RG0100X, 207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD316941300Medicaid
MDMI89Medicare ID - Type UnspecifiedINDIVIDUAL
MDC49125Medicare UPIN
MDKR68JHMedicare ID - Type UnspecifiedGROUP