Provider Demographics
NPI:1013968080
Name:MITCHELL, ANTHONY L (MD)
Entity Type:Individual
Prefix:DR
First Name:ANTHONY
Middle Name:L
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 1:1100 WILFORD HALL LOOP BLDG 4554
Mailing Address - Street 2:
Mailing Address - City:JBSA LACKLAND
Mailing Address - State:TX
Mailing Address - Zip Code:78236-5638
Mailing Address - Country:US
Mailing Address - Phone:210-292-3442
Mailing Address - Fax:
Practice Address - Street 1:1100 WILFORD HALL LOOP
Practice Address - Street 2:
Practice Address - City:JBSA LACKLAND
Practice Address - State:TX
Practice Address - Zip Code:78236-5638
Practice Address - Country:US
Practice Address - Phone:210-292-3442
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-05-15
Last Update Date:2023-08-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXU4431207P00000X, 207RC0200X
LA024342207P00000X, 207RC0200X
GA057221207P00000X, 207RC0200X
MDD69403207RC0200X, 207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
No207RC0200XAllopathic & Osteopathic PhysiciansInternal MedicineCritical Care Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA342360871AMedicaid
MD419682100Medicaid
GA52173131OtherBCBS
GA361896OtherWELLCARE
GAP00334342OtherRAILRAOD MEDICARE
GA0137OtherBLUE CROSS
MD0137OtherBLUE CROSS
GA342360871BMedicaid
GA93BFCJNMedicare PIN
GA0137OtherBLUE CROSS
GA342360871AMedicaid