Provider Demographics
NPI:1871505123
Name:MITCHELL, MATTHEW DAVID (OD)
Entity Type:Individual
Prefix:DR
First Name:MATTHEW
Middle Name:DAVID
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:PO BOX 374
Mailing Address - Street 2:
Mailing Address - City:BLUFFTON
Mailing Address - State:IN
Mailing Address - Zip Code:46714-0374
Mailing Address - Country:US
Mailing Address - Phone:260-824-3424
Mailing Address - Fax:260-824-9116
Practice Address - Street 1:105 W HARVEST RD
Practice Address - Street 2:
Practice Address - City:BLUFFTON
Practice Address - State:IN
Practice Address - Zip Code:46714-9007
Practice Address - Country:US
Practice Address - Phone:260-824-3424
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-13
Last Update Date:2007-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN18003000A152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN18003000OtherLICENSE#
IN000000528552OtherBCBS
IN182520DMedicare PIN
INU77768Medicare UPIN
IN4211170001Medicare NSC