Provider Demographics
NPI:1184604803
Name:CHRISTENSEN, MITCHELL PAUL (OD)
Entity type:Individual
Prefix:DR
First Name:MITCHELL
Middle Name:PAUL
Last Name:CHRISTENSEN
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:MITCH
Other - Middle Name:
Other - Last Name:CHRISTENSEN
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:1950 OLD GALLOWS RD STE 520
Mailing Address - Street 2:
Mailing Address - City:VIENNA
Mailing Address - State:VA
Mailing Address - Zip Code:22182-3970
Mailing Address - Country:US
Mailing Address - Phone:703-847-8899
Mailing Address - Fax:571-223-6780
Practice Address - Street 1:6555 SUGARLOAF PKWY
Practice Address - Street 2:SUITE 303
Practice Address - City:DULUTH
Practice Address - State:GA
Practice Address - Zip Code:30097-4930
Practice Address - Country:US
Practice Address - Phone:770-495-0937
Practice Address - Fax:678-417-6000
Is Sole Proprietor?:No
Enumeration Date:2006-01-19
Last Update Date:2021-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAOPT001764152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GAU99759Medicare UPIN
GA41ZCFNLMedicare PIN