Provider Demographics
NPI:1750721031
Name:OETKEN, MITCHELL (DO)
Entity type:Individual
Prefix:DR
First Name:MITCHELL
Middle Name:
Last Name:OETKEN
Suffix:
Gender:M
Credentials:DO
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 935722
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:31193-5722
Mailing Address - Country:US
Mailing Address - Phone:843-792-6200
Mailing Address - Fax:
Practice Address - Street 1:1025 W MEETING ST STE 100
Practice Address - Street 2:
Practice Address - City:LANCASTER
Practice Address - State:SC
Practice Address - Zip Code:29720-2245
Practice Address - Country:US
Practice Address - Phone:803-285-3700
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-07-01
Last Update Date:2022-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN02005308A207X00000X, 208600000X
390200000X
SC87761207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
No208600000XAllopathic & Osteopathic PhysiciansSurgery
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program