Provider Demographics
NPI:1811149685
Name:MITCHELL, KIRK ERNEST (MD)
Entity type:Individual
Prefix:DR
First Name:KIRK
Middle Name:ERNEST
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 1:5390 SAINT VRAIN RD
Mailing Address - Street 2:
Mailing Address - City:LONGMONT
Mailing Address - State:CO
Mailing Address - Zip Code:80503-8764
Mailing Address - Country:US
Mailing Address - Phone:303-859-9722
Mailing Address - Fax:303-484-3578
Practice Address - Street 1:5390 SAINT VRAIN RD
Practice Address - Street 2:
Practice Address - City:LONGMONT
Practice Address - State:CO
Practice Address - Zip Code:80503-8764
Practice Address - Country:US
Practice Address - Phone:303-859-9722
Practice Address - Fax:303-484-3578
Is Sole Proprietor?:Yes
Enumeration Date:2008-10-10
Last Update Date:2021-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CODR.0049886207Q00000X, 207R00000X, 207RG0300X
WY8019A207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RG0300XAllopathic & Osteopathic PhysiciansInternal MedicineGeriatric MedicineGroup - Multi-Specialty
No207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO08227519Medicaid
CO370968YLB8Medicare PIN
WYW22596Medicare PIN
CO370968YLMEMedicare PIN
WYW23709Medicare PIN
WYW23627Medicare PIN