Provider Demographics
| NPI: | 1245612969 |
|---|---|
| Name: | STOTLAND, MITCHELL (MD) |
| Entity type: | Individual |
| Prefix: | |
| First Name: | MITCHELL |
| Middle Name: | |
| Last Name: | STOTLAND |
| 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: | 2885 SANFORD AVE SW STE 46566 |
| Mailing Address - Street 2: | |
| Mailing Address - City: | GRANDVILLE |
| Mailing Address - State: | MI |
| Mailing Address - Zip Code: | 49418-1342 |
| Mailing Address - Country: | US |
| Mailing Address - Phone: | |
| Mailing Address - Fax: | |
| Practice Address - Street 1: | 2637 E ATLANTIC BLVD STE 46566 |
| Practice Address - Street 2: | |
| Practice Address - City: | POMPANO BEACH |
| Practice Address - State: | FL |
| Practice Address - Zip Code: | 33062-4939 |
| Practice Address - Country: | US |
| Practice Address - Phone: | 724-299-1220 |
| Practice Address - Fax: | |
| Is Sole Proprietor?: | Yes |
| Enumeration Date: | 2015-06-19 |
| Last Update Date: | 2025-01-27 |
| Deactivation Date: | |
| Deactivation Code: | |
| Reactivation Date: |
Provider Licenses
| State | License ID | Taxonomies |
|---|---|---|
| PA | MD468233 | 2083X0100X |
| MD | D0088242 | 2083X0100X |
| GA | 83897 | 2083X0100X |
| VA | 0101267722 | 2083X0100X |
| MI | 4301500489 | 2083X0100X |
| AZ | 59141 | 2083X0100X |
| AL | 38550 | 2083X0100X |
| AR | E-12568 | 2083X0100X |
| AK | 150879 | 2083X0100X |
| KY | 53070 | 2083X0100X |
| IN | 01078523A | 2083X0100X |
| CA | A165176 | 2083X0100X |
| WV | 28795 | 208D00000X |
| 390200000X | ||
| FL | ME141497 | 2083P0901X |
Provider Taxonomies
| Primary? | Code | Type | Classification | Specialization |
|---|---|---|---|---|
| Yes | 2083P0901X | Allopathic & Osteopathic Physicians | Preventive Medicine | Public Health & General Preventive Medicine |
| No | 2083X0100X | Allopathic & Osteopathic Physicians | Preventive Medicine | Occupational Medicine |
| No | 208D00000X | Allopathic & Osteopathic Physicians | General Practice | |
| No | 390200000X | Student, Health Care | Student in an Organized Health Care Education/Training Program |
Provider Identifiers
| State | Identifier ID | ID Type | Issuer |
|---|---|---|---|
| MI | 4301500489 | Other | STATE LICENSE |
| MN | 66243 | Other | STATE LICENSE |
| DE | C1-0013395 | Other | STATE LICENSE |
| DC | MD048607 | Other | STATE LICENSE |
| WA | MD60972416 | Other | STATE LICENSE |
| IL | 036150640 | Other | STATE LICENSE |
| ND | 16110 | Other | STATE LICENSE |
| AL | 38550 | Other | LICENSE |
| KY | 53070 | Other | STATE LICENSE |
| MD | D0088242 | Other | STATE LICENSE |
| FL | ME141497 | Other | FLORIDA |
| MT | MED-PHYS-LIC87942 | Other | STATE LICENSE |
| OK | 35092 | Other | STATE LICENSE |
| TN | 59945 | Other | STATE LICENSE |
| SC | 82992 | Other | STATE LICENSE |
| GA | 83897 | Other | GEORGIA |
| HI | MD20739 | Other | STATE LICENSE |
| ME | MD23245 | Other | STATE LICENSE |
| TX | S3935 | Other | STATE LICENSE |
| IN | 01078523A | Other | LICENSE |
| SD | 12115 | Other | STATE LICENSE |
| AK | 150879 | Other | STATE LICENSE |
| OH | 35.136962CTR | Other | STATE LICENSE |
| WI | 71877-20 | Other | STATE LICENSE |
| VA | 0101267722 | Other | STATE LICENSE |
| MS | 27184 | Other | STATE LICENSE |
| NY | 300527 | Other | STATE LICENSE |
| RI | MD16846 | Other | STATE LICENSE |
| KS | 04-42551 | Other | STATE LICENSE |
| WY | 12446A | Other | STATE LICENSE |
| NH | 19979 | Other | STATE LICENSE |
| NC | 252874 | Other | NC |
| NJ | 25MA10667900 | Other | STATE LICENSE |
| MA | 281631 | Other | STATE LICENSE |
| WV | 28795 | Other | STATE LICENSE |
| NE | 32094 | Other | STATE LICENSE |
| AZ | 59141 | Other | LICENSE |
| CO | DR.0062841 | Other | STATE LICENSE |
| FL | ME141497 | Other | LICENSE |
| MO | 2019024778 | Other | STATE LICENSE |
| LA | 320861 | Other | STATE LICENSE |
| CA | A165176 | Other | STATE LICENSE |
| AR | E-12568 | Other | STATE LICENSE |
| ID | M-14856 | Other | STATE LICENSE |
| IA | MD-46545 | Other | STATE LICENSE |
| OR | MD195637 | Other | STATE LICENSE |
| NM | MD2019-0869 | Other | STATE LICENSE |
| UT | 11351098-1205 | Other | STATE LICENSE |
| NV | 20824 | Other | STATE LICENSE |
| PA | MD468233 | Other | STATE LICENSE |
