Provider Demographics
NPI:1881687291
Name:MITCHELL, THOMAS RAYMOND (MD)
Entity Type:Individual
Prefix:
First Name:THOMAS
Middle Name:RAYMOND
Last Name:MITCHELL
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 1:2675 WINKLER AVE FL 2
Mailing Address - Street 2:
Mailing Address - City:FORT MYERS
Mailing Address - State:FL
Mailing Address - Zip Code:33901-9342
Mailing Address - Country:US
Mailing Address - Phone:877-856-3774
Mailing Address - Fax:
Practice Address - Street 1:126 DEL PRADO BLVD N STE 102
Practice Address - Street 2:
Practice Address - City:CAPE CORAL
Practice Address - State:FL
Practice Address - Zip Code:33909-2713
Practice Address - Country:US
Practice Address - Phone:239-772-8900
Practice Address - Fax:239-985-9762
Is Sole Proprietor?:No
Enumeration Date:2005-08-31
Last Update Date:2023-12-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY180983207Q00000X
FLME126035207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01161586Medicaid
NY01161586Medicaid
38331DMedicare ID - Type Unspecified
38331DMedicare ID - Type Unspecified