Provider Demographics
NPI:1831114685
Name:MITCHELL, BLAINE PARRISH (DO)
Entity Type:Individual
Prefix:
First Name:BLAINE
Middle Name:PARRISH
Last Name:MITCHELL
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:500 N HIATUS RD STE 200
Mailing Address - Street 2:
Mailing Address - City:PEMBROKE PINES
Mailing Address - State:FL
Mailing Address - Zip Code:33026-5213
Mailing Address - Country:US
Mailing Address - Phone:954-437-4800
Mailing Address - Fax:954-437-6628
Practice Address - Street 1:3501 JOHNSON ST
Practice Address - Street 2:
Practice Address - City:HOLLYWOOD
Practice Address - State:FL
Practice Address - Zip Code:33021-5421
Practice Address - Country:US
Practice Address - Phone:954-437-4800
Practice Address - Fax:954-437-6628
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-13
Last Update Date:2021-12-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDH776822085R0202X
FLOS97352085R0202X, 2085R0204X, 2085R0202X
IN02003016A2085R0204X
MI51010163072085R0204X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
No2085R0204XAllopathic & Osteopathic PhysiciansRadiologyVascular & Interventional Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD404985ZAGYMedicare PIN