Provider Demographics
NPI:1750339651
Name:MITCHELL, JERRY (MD)
Entity type:Individual
Prefix:
First Name:JERRY
Middle Name:
Last Name:MITCHELL
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2315 WILDCAT RUN CT
Mailing Address - Street 2:
Mailing Address - City:POWELL
Mailing Address - State:OH
Mailing Address - Zip Code:43065-5112
Mailing Address - Country:US
Mailing Address - Phone:614-406-1926
Mailing Address - Fax:
Practice Address - Street 1:2315 WILDCAT RUN CT
Practice Address - Street 2:
Practice Address - City:POWELL
Practice Address - State:OH
Practice Address - Zip Code:43065-5112
Practice Address - Country:US
Practice Address - Phone:614-406-1926
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-05-04
Last Update Date:2021-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35082344207RH0002X, 207RX0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RX0202XAllopathic & Osteopathic PhysiciansInternal MedicineMedical Oncology
No207RH0002XAllopathic & Osteopathic PhysiciansInternal MedicineHospice and Palliative Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2425763Medicaid
OH000000288885OtherANTHEM BC/BS
OH3600950OtherUNITED HEALTHCARE
OH2425763Medicaid
OH4110991Medicare PIN