Provider Demographics
NPI:1700132719
Name:MITCHELL, EDWIN KYLE (OD)
Entity Type:Individual
Prefix:DR
First Name:EDWIN
Middle Name:KYLE
Last Name:MITCHELL
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:316 WINDING WOOD CIR
Mailing Address - Street 2:
Mailing Address - City:BLYTHEWOOD
Mailing Address - State:SC
Mailing Address - Zip Code:29016-7843
Mailing Address - Country:US
Mailing Address - Phone:803-776-5363
Mailing Address - Fax:803-227-8996
Practice Address - Street 1:1150 S 4TH ST
Practice Address - Street 2:
Practice Address - City:HARTSVILLE
Practice Address - State:SC
Practice Address - Zip Code:29550-0705
Practice Address - Country:US
Practice Address - Phone:843-857-1999
Practice Address - Fax:843-383-8951
Is Sole Proprietor?:Yes
Enumeration Date:2012-07-27
Last Update Date:2015-04-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC1696152W00000X, 152WC0802X, 152WP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
No152WC0802XEye and Vision Services ProvidersOptometristCorneal and Contact Management
No152WP0200XEye and Vision Services ProvidersOptometristPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCD16962Medicaid
SCSC3405OtherMEDICARE PTAN HV
SCSC0144OtherMEDICARE PTAN