Provider Demographics
NPI:1760555890
Name:MITCHELL, GLENN WHITTAKER (MD,)
Entity Type:Individual
Prefix:DR
First Name:GLENN
Middle Name:WHITTAKER
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 1:14528 S OUTER 40 STE 100
Mailing Address - Street 2:
Mailing Address - City:CHESTERFIELD
Mailing Address - State:MO
Mailing Address - Zip Code:63017-5743
Mailing Address - Country:US
Mailing Address - Phone:314-628-3838
Mailing Address - Fax:
Practice Address - Street 1:14528 S OUTER 40 STE 100
Practice Address - Street 2:
Practice Address - City:CHESTERFIELD
Practice Address - State:MO
Practice Address - Zip Code:63017-5743
Practice Address - Country:US
Practice Address - Phone:314-628-3838
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-11-16
Last Update Date:2008-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXM0829207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZI28678Medicare UPIN