Provider Demographics
NPI:1356436851
Name:MITHLO, MARIA MERCEDES (MD)
Entity type:Individual
Prefix:
First Name:MARIA
Middle Name:MERCEDES
Last Name:MITHLO
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8148 STATE HIGHWAY 17
Mailing Address - Street 2:
Mailing Address - City:ELGIN
Mailing Address - State:OK
Mailing Address - Zip Code:73538-9010
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:405-701-7914
Practice Address - Street 1:8148 STATE HIGHWAY 17
Practice Address - Street 2:
Practice Address - City:ELGIN
Practice Address - State:OK
Practice Address - Zip Code:73538-9010
Practice Address - Country:US
Practice Address - Phone:580-454-2273
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-03
Last Update Date:2023-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK21319207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK100220880AMedicaid
OKE74312Medicare UPIN