Provider Demographics
NPI:1255388666
Name:MITCHELL, KEVIN (MD)
Entity type:Individual
Prefix:
First Name:KEVIN
Middle Name:
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 1:5400 SPENCER LN
Mailing Address - Street 2:
Mailing Address - City:GRANITE BAY
Mailing Address - State:CA
Mailing Address - Zip Code:95746-6305
Mailing Address - Country:US
Mailing Address - Phone:916-783-6230
Mailing Address - Fax:
Practice Address - Street 1:710 4TH ST
Practice Address - Street 2:SUITE B
Practice Address - City:MARYSVILLE
Practice Address - State:CA
Practice Address - Zip Code:95901-5668
Practice Address - Country:US
Practice Address - Phone:530-749-0700
Practice Address - Fax:530-749-9298
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-30
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO1040942086S0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2086S0102XAllopathic & Osteopathic PhysiciansSurgerySurgical Critical Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G867120Medicaid
CA00G867120Medicaid
MOE18514Medicare UPIN