Provider Demographics
NPI:1740940782
Name:TULLEDGE MITCHELL, JEREMY (PT)
Entity type:Individual
Prefix:
First Name:JEREMY
Middle Name:
Last Name:TULLEDGE MITCHELL
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 267
Mailing Address - Street 2:
Mailing Address - City:COLCHESTER
Mailing Address - State:CT
Mailing Address - Zip Code:06415-0267
Mailing Address - Country:US
Mailing Address - Phone:860-537-3014
Mailing Address - Fax:860-537-1420
Practice Address - Street 1:171 NORWICH AVE
Practice Address - Street 2:
Practice Address - City:COLCHESTER
Practice Address - State:CT
Practice Address - Zip Code:06415-1274
Practice Address - Country:US
Practice Address - Phone:860-537-3014
Practice Address - Fax:860-537-1420
Is Sole Proprietor?:No
Enumeration Date:2021-12-17
Last Update Date:2021-12-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT13372208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation