Provider Demographics
NPI:1891993416
Name:MITCHELL C. PRESTON MD PLLC
Entity Type:Organization
Organization Name:MITCHELL C. PRESTON MD PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DOCTOR
Authorized Official - Prefix:
Authorized Official - First Name:MITCHELL
Authorized Official - Middle Name:C
Authorized Official - Last Name:PRESTON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:928-649-9519
Mailing Address - Street 1:PO BOX 4420
Mailing Address - Street 2:
Mailing Address - City:COTTONWOOD
Mailing Address - State:AZ
Mailing Address - Zip Code:86326-2574
Mailing Address - Country:US
Mailing Address - Phone:928-649-9519
Mailing Address - Fax:928-649-9967
Practice Address - Street 1:1759 E VILLA DR
Practice Address - Street 2:SUITE 114
Practice Address - City:COTTONWOOD
Practice Address - State:AZ
Practice Address - Zip Code:86326-4681
Practice Address - Country:US
Practice Address - Phone:928-649-9519
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-07-05
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ31874207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ821753OtherAHCCCS ID
AZG46196Medicare UPIN
AZZ78562Medicare ID - Type Unspecified