Provider Demographics
NPI:1013107499
Name:MITCHELL, MARK ANTHONY (IDC)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:ANTHONY
Last Name:MITCHELL
Suffix:
Gender:M
Credentials:IDC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1140 KELLUM LOOP RD
Mailing Address - Street 2:#36
Mailing Address - City:JACKSONVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28546-3321
Mailing Address - Country:US
Mailing Address - Phone:917-603-6469
Mailing Address - Fax:
Practice Address - Street 1:1140 KELLUM LOOP RD
Practice Address - Street 2:#36
Practice Address - City:JACKSONVILLE
Practice Address - State:NC
Practice Address - Zip Code:28546-3321
Practice Address - Country:US
Practice Address - Phone:917-603-6469
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-07-31
Last Update Date:2007-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1710I1002XOther Service ProvidersMilitary Health Care ProviderIndependent Duty Corpsman