Provider Demographics
NPI:1982051660
Name:MITCHELL, MARY MORGAN (DO)
Entity Type:Individual
Prefix:
First Name:MARY MORGAN
Middle Name:
Last Name:MITCHELL
Suffix:
Gender:F
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:PO BOX 1088
Mailing Address - Street 2:
Mailing Address - City:PULASKI
Mailing Address - State:VA
Mailing Address - Zip Code:24301-1088
Mailing Address - Country:US
Mailing Address - Phone:540-980-0922
Mailing Address - Fax:
Practice Address - Street 1:1691 INNOVATION DR STE 2100
Practice Address - Street 2:
Practice Address - City:BLACKSBURG
Practice Address - State:VA
Practice Address - Zip Code:24060-6618
Practice Address - Country:US
Practice Address - Phone:540-232-8405
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-05-23
Last Update Date:2020-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0102205725207Q00000X, 207QS0010X
MI5101022404207Q00000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207QS0010XAllopathic & Osteopathic PhysiciansFamily MedicineSports Medicine
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program