Provider Demographics
NPI:1790731230
Name:IMM, MITCHELL DONGJUN (MD)
Entity Type:Individual
Prefix:DR
First Name:MITCHELL
Middle Name:DONGJUN
Last Name:IMM
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 1:10647 BRAMBLECREST DR
Mailing Address - Street 2:
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78726-1906
Mailing Address - Country:US
Mailing Address - Phone:512-906-1974
Mailing Address - Fax:
Practice Address - Street 1:10647 BRAMBLECREST DR
Practice Address - Street 2:
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78726-1906
Practice Address - Country:US
Practice Address - Phone:512-906-1974
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-05-26
Last Update Date:2008-09-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC200200707208000000X, 2080N0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080N0001XAllopathic & Osteopathic PhysiciansPediatricsNeonatal-Perinatal Medicine
No208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC89131UTMedicaid
NC131UTOtherBCBS NC
NC7355461OtherAETNA
NCD8866OtherMEDCOST
NC7355461OtherAETNA