Provider Demographics
NPI:1356341721
Name:MITCHELL, CHARLES HOWARD (DO)
Entity type:Individual
Prefix:
First Name:CHARLES
Middle Name:HOWARD
Last Name:MITCHELL
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:200 MELVILLE DR
Mailing Address - Street 2:
Mailing Address - City:PAULS VALLEY
Mailing Address - State:OK
Mailing Address - Zip Code:73075-6600
Mailing Address - Country:US
Mailing Address - Phone:405-238-5555
Mailing Address - Fax:405-238-6348
Practice Address - Street 1:200 MELVILLE DR
Practice Address - Street 2:
Practice Address - City:PAULS VALLEY
Practice Address - State:OK
Practice Address - Zip Code:73075-6600
Practice Address - Country:US
Practice Address - Phone:405-238-5555
Practice Address - Fax:405-238-6348
Is Sole Proprietor?:Yes
Enumeration Date:2005-07-28
Last Update Date:2018-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK2248208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK100089620AMedicaid
OKE09666Medicare UPIN