Provider Demographics
NPI: | 1932113735 |
---|---|
Name: | MITCHELL, BAKER A III (MD) |
Entity Type: | Individual |
Prefix: | |
First Name: | BAKER |
Middle Name: | A |
Last Name: | MITCHELL |
Suffix: | III |
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: | 345 FLATWOODS FOREST LOOP |
Mailing Address - Street 2: | |
Mailing Address - City: | SANTA ROSA BEACH |
Mailing Address - State: | FL |
Mailing Address - Zip Code: | 32459-8843 |
Mailing Address - Country: | US |
Mailing Address - Phone: | 210-884-3779 |
Mailing Address - Fax: | |
Practice Address - Street 1: | 100 N RICHARD JACKSON BLVD STE 120 |
Practice Address - Street 2: | |
Practice Address - City: | PANAMA CITY BEACH |
Practice Address - State: | FL |
Practice Address - Zip Code: | 32407 |
Practice Address - Country: | US |
Practice Address - Phone: | 850-226-6801 |
Practice Address - Fax: | |
Is Sole Proprietor?: | No |
Enumeration Date: | 2006-07-28 |
Last Update Date: | 2019-01-31 |
Deactivation Date: | |
Deactivation Code: | |
Reactivation Date: |
Provider Licenses
State | License ID | Taxonomies |
---|---|---|
NY | 254963 | 207L00000X |
TX | P1108 | 207L00000X, 207LP2900X |
FL | ME134995 | 207LP2900X |
Provider Taxonomies
Primary? | Code | Type | Classification | Specialization |
---|---|---|---|---|
Yes | 207LP2900X | Allopathic & Osteopathic Physicians | Anesthesiology | Pain Medicine |
No | 207L00000X | Allopathic & Osteopathic Physicians | Anesthesiology |
Provider Identifiers
State | Identifier ID | ID Type | Issuer |
---|---|---|---|
TX | 286138701 | Medicaid | |
TX | 286138701 | Medicaid |