Provider Demographics
NPI:1851804553
Name:BARROS, MITCHELL GERALD PLANA
Entity Type:Individual
Prefix:
First Name:MITCHELL GERALD
Middle Name:PLANA
Last Name:BARROS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1093 A1A BEACH BLVD # 198
Mailing Address - Street 2:
Mailing Address - City:SAINT AUGUSTINE
Mailing Address - State:FL
Mailing Address - Zip Code:32080-6733
Mailing Address - Country:US
Mailing Address - Phone:904-315-2881
Mailing Address - Fax:
Practice Address - Street 1:150 SOUTHPARK BLVD STE 204D
Practice Address - Street 2:
Practice Address - City:SAINT AUGUSTINE
Practice Address - State:FL
Practice Address - Zip Code:32086-5179
Practice Address - Country:US
Practice Address - Phone:904-315-2881
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-11-16
Last Update Date:2020-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA294088225100000X
FL35921225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist