Provider Demographics
NPI:1811988751
Name:MITCHELL, KELLY T (MD)
Entity type:Individual
Prefix:DR
First Name:KELLY
Middle Name:T
Last Name:MITCHELL
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
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Mailing Address - Street 1:PO BOX 5865
Mailing Address - Street 2:
Mailing Address - City:LUBBOCK
Mailing Address - State:TX
Mailing Address - Zip Code:79408-5865
Mailing Address - Country:US
Mailing Address - Phone:806-743-2898
Mailing Address - Fax:806-743-2787
Practice Address - Street 1:3601 4TH ST
Practice Address - Street 2:2A100
Practice Address - City:LUBBOCK
Practice Address - State:TX
Practice Address - Zip Code:79430-0002
Practice Address - Country:US
Practice Address - Phone:806-743-2020
Practice Address - Fax:806-743-1782
Is Sole Proprietor?:No
Enumeration Date:2005-10-31
Last Update Date:2014-01-06
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
TXL1942207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX144792205Medicaid
TX144792206Medicaid
NM81940Medicaid
OK200013870AMedicaid
TX87410ZOtherHMO BLUE
NM08534730Medicaid
TX8G7982OtherBC/BS
TX101449101Medicaid
NM81940OtherPRESBYTERIAN COMMERCIAL
NMA582OtherTRIWEST
TX101449100OtherFIRSTCARE COMMERCIAL
TX8A9915Medicare PIN
TX101449100OtherFIRSTCARE COMMERCIAL
TX8G7982OtherBC/BS