Provider Demographics
NPI:1780193763
Name:MITCHELL, MARCIA MARIE (MD)
Entity Type:Individual
Prefix:MRS
First Name:MARCIA
Middle Name:MARIE
Last Name:MITCHELL
Suffix:
Gender:F
Credentials:MD
Other - Prefix:MS
Other - First Name:MARCIA
Other - Middle Name:MARIE
Other - Last Name:KELLER
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:PO BOX 711640
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84171
Mailing Address - Country:US
Mailing Address - Phone:801-501-9734
Mailing Address - Fax:
Practice Address - Street 1:4 LONGWOOD LANE
Practice Address - Street 2:
Practice Address - City:SANDY
Practice Address - State:UT
Practice Address - Zip Code:84092
Practice Address - Country:US
Practice Address - Phone:801-501-9734
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-09-22
Last Update Date:2017-09-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT149372-1205207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine