Provider Demographics
NPI:1356372197
Name:MITCHELL, CHARLES L (DPM)
Entity type:Individual
Prefix:
First Name:CHARLES
Middle Name:L
Last Name:MITCHELL
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:1424 E 53RD ST
Mailing Address - Street 2:SUITE 301
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60615-4500
Mailing Address - Country:US
Mailing Address - Phone:773-324-3338
Mailing Address - Fax:773-324-1866
Practice Address - Street 1:1424 E 53RD ST
Practice Address - Street 2:SUITE 301
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60615-4500
Practice Address - Country:US
Practice Address - Phone:773-324-3338
Practice Address - Fax:773-324-1866
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-06
Last Update Date:2015-04-30
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
IL016-004908213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL1634266OtherBLUE CROSS BLUE SHIELD
ILP00243141OtherRAILROAD MEDICARE
IL016004908Medicaid
IL609279300OtherDEPT OF LABOR
IL1634266OtherBLUE CROSS BLUE SHIELD
IL016004908Medicaid