Provider Demographics
NPI:1932192044
Name:MITCHELL, CARL ISSAC (MD)
Entity Type:Individual
Prefix:DR
First Name:CARL
Middle Name:ISSAC
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 1:7201 BROOKFIELD RD
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA
Mailing Address - State:SC
Mailing Address - Zip Code:29223-2215
Mailing Address - Country:US
Mailing Address - Phone:803-736-4050
Mailing Address - Fax:803-736-4083
Practice Address - Street 1:7201 BROOKFIELD RD
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:SC
Practice Address - Zip Code:29223-2215
Practice Address - Country:US
Practice Address - Phone:803-736-4050
Practice Address - Fax:803-736-4083
Is Sole Proprietor?:Yes
Enumeration Date:2005-08-24
Last Update Date:2011-09-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC8063207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC080637Medicaid
SC4033Medicare PIN
SCC60995Medicare UPIN