Provider Demographics
NPI:1265620363
Name:MITCHELL, MARC A (DO)
Entity type:Individual
Prefix:DR
First Name:MARC
Middle Name:A
Last Name:MITCHELL
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:9621 RIDGETOP BLVD NW
Mailing Address - Street 2:
Mailing Address - City:SILVERDALE
Mailing Address - State:WA
Mailing Address - Zip Code:98383-8502
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:9398 RIDGETOP BLVD NW
Practice Address - Street 2:
Practice Address - City:SILVERDALE
Practice Address - State:WA
Practice Address - Zip Code:98383-8505
Practice Address - Country:US
Practice Address - Phone:360-782-3222
Practice Address - Fax:360-782-3245
Is Sole Proprietor?:No
Enumeration Date:2007-10-15
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5101016185208800000X
WAOP60085623208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA1010MIOtherREGENCE
WA249177OtherLABOR & INDUSTRIES
WA249177OtherLABOR & INDUSTRIES
G8881644Medicare PIN
G8887637Medicare PIN
WA249177OtherLABOR & INDUSTRIES
G8881645Medicare PIN
G8890355Medicare PIN
WA1010MIOtherREGENCE
G8888464Medicare PIN