Provider Demographics
NPI:1851362339
Name:MITCHELL, MIKE (OD)
Entity Type:Individual
Prefix:DR
First Name:MIKE
Middle Name:
Last Name:MITCHELL
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:328 CENTER ST
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84103-1625
Mailing Address - Country:US
Mailing Address - Phone:801-364-3749
Mailing Address - Fax:801-268-6602
Practice Address - Street 1:201 E 5900 S
Practice Address - Street 2:SUITE 101
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84107-7379
Practice Address - Country:US
Practice Address - Phone:801-268-6600
Practice Address - Fax:801-268-6602
Is Sole Proprietor?:Yes
Enumeration Date:2006-01-31
Last Update Date:2011-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT1138589934152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
UTT98162Medicare UPIN