Provider Demographics
NPI:1811139462
Name:MITCHELL, EDWARD JR (LDO)
Entity type:Individual
Prefix:MR
First Name:EDWARD
Middle Name:
Last Name:MITCHELL
Suffix:JR
Gender:M
Credentials:LDO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4100 S FERDON BLVD STE B5
Mailing Address - Street 2:
Mailing Address - City:CRESTVIEW
Mailing Address - State:FL
Mailing Address - Zip Code:32536-5287
Mailing Address - Country:US
Mailing Address - Phone:850-758-0474
Mailing Address - Fax:850-682-0057
Practice Address - Street 1:4100 S FERDON BLVD STE B5
Practice Address - Street 2:
Practice Address - City:CRESTVIEW
Practice Address - State:FL
Practice Address - Zip Code:32536-5287
Practice Address - Country:US
Practice Address - Phone:850-758-0474
Practice Address - Fax:850-682-0057
Is Sole Proprietor?:Yes
Enumeration Date:2009-03-28
Last Update Date:2019-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDO 5539156FC0801X, 156FX1800X
FL5539156FX1800X
FLDO5539332H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332H00000XSuppliersEyewear Supplier
No156FC0801XEye and Vision Services ProvidersTechnician/TechnologistContact Lens Fitter
No156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOptician
Provider Identifiers
StateIdentifier IDID TypeIssuer
80-0442282OtherIRS