Provider Demographics
NPI:1922082197
Name:MITCHELL, MICHAEL D (MD)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:D
Last Name:MITCHELL
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Mailing Address - Street 1:5945 DAMON HILL RD
Mailing Address - Street 2:
Mailing Address - City:SINCLAIRVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:14782-9728
Mailing Address - Country:US
Mailing Address - Phone:716-397-0814
Mailing Address - Fax:716-338-1575
Practice Address - Street 1:51 GLASGOW AVE.
Practice Address - Street 2:
Practice Address - City:JAMESTOWN
Practice Address - State:NY
Practice Address - Zip Code:14701
Practice Address - Country:US
Practice Address - Phone:716-664-8604
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-12-01
Last Update Date:2019-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY1628872081S0010X, 207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No2081S0010XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationSports Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00902103Medicaid
NY00902103Medicaid
NYD74805Medicare UPIN