Provider Demographics
NPI:1962567719
Name:MITCHELL, FRED L (DO)
Entity type:Individual
Prefix:
First Name:FRED
Middle Name:L
Last Name:MITCHELL
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 1:906 LANTERN HILL DR
Mailing Address - Street 2:
Mailing Address - City:EAST LANSING
Mailing Address - State:MI
Mailing Address - Zip Code:48823-2832
Mailing Address - Country:US
Mailing Address - Phone:517-351-5248
Mailing Address - Fax:
Practice Address - Street 1:906 LANTERN HILL DR
Practice Address - Street 2:
Practice Address - City:EAST LANSING
Practice Address - State:MI
Practice Address - Zip Code:48823-2832
Practice Address - Country:US
Practice Address - Phone:517-351-5248
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5101006537208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI0153333765OtherBCBS OF MICHIGAN
MI5333376Medicare ID - Type Unspecified
MI0153333765OtherBCBS OF MICHIGAN