Provider Demographics
NPI:1205975422
Name:MITCHELL, WILLIAM EDGEFIELD JR (MD)
Entity type:Individual
Prefix:
First Name:WILLIAM
Middle Name:EDGEFIELD
Last Name:MITCHELL
Suffix:JR
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 1:9A ROCKY SLOPE DR
Mailing Address - Street 2:
Mailing Address - City:SANTA FE
Mailing Address - State:NM
Mailing Address - Zip Code:87508-1345
Mailing Address - Country:US
Mailing Address - Phone:505-473-3648
Mailing Address - Fax:
Practice Address - Street 1:9A ROCKY SLOPE DR
Practice Address - Street 2:
Practice Address - City:SANTA FE
Practice Address - State:NM
Practice Address - Zip Code:87508-1345
Practice Address - Country:US
Practice Address - Phone:505-473-3648
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-02-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA09213208600000X
NM2002061208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
D46162Medicare UPIN