Provider Demographics
NPI:1780674101
Name:MITCHELL, KIMBERLY RAYE (OD)
Entity Type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:RAYE
Last Name:MITCHELL
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:KIMBERLY
Other - Middle Name:RAYE
Other - Last Name:PATTERSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:OD
Mailing Address - Street 1:215 W MAIN ST
Mailing Address - Street 2:
Mailing Address - City:CABOT
Mailing Address - State:AR
Mailing Address - Zip Code:72023-2944
Mailing Address - Country:US
Mailing Address - Phone:501-843-7511
Mailing Address - Fax:501-605-0905
Practice Address - Street 1:215 W MAIN ST
Practice Address - Street 2:
Practice Address - City:CABOT
Practice Address - State:AR
Practice Address - Zip Code:72023-2944
Practice Address - Country:US
Practice Address - Phone:501-843-7511
Practice Address - Fax:501-605-0905
Is Sole Proprietor?:No
Enumeration Date:2005-10-26
Last Update Date:2017-03-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR2376152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR120426722Medicaid
T86926Medicare UPIN
AR120426722Medicaid