Basic Information
| Provider Information | |||||||||
| NPI: | 1013110121 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MITCHELL | ||||||||
| FirstName: | DIANNE | ||||||||
| MiddleName: | ILENE | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | DPM | ||||||||
| OtherOrganizationName: | |||||||||
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| OtherLastName: | |||||||||
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| OtherCredential: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 3000 Q ST | ||||||||
| Address2: | 4TH FLOOR PODIATRY | ||||||||
| City: | SACRAMENTO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 958167058 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9167333359 | ||||||||
| FaxNumber: | 9167333462 | ||||||||
| Practice Location | |||||||||
| Address1: | 3000 Q ST | ||||||||
| Address2: | 4TH FLOOR PODIATRY | ||||||||
| City: | SACRAMENTO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 958167058 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9167333359 | ||||||||
| FaxNumber: | 9167333462 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/06/2007 | ||||||||
| LastUpdateDate: | 09/26/2012 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| AuthorizedOfficialTitleorPosition: | |||||||||
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| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 213ES0103X | PO00000826 | WA | N | Podiatric Medicine & Surgery Service Providers | Podiatrist | Foot & Ankle Surgery | 213ES0103X | E-4683 | CA | Y | Podiatric Medicine & Surgery Service Providers | Podiatrist | Foot & Ankle Surgery |
ID Information
| ID | Type | State | Issuer | Description | 4283MI | 01 | WA | BLUE SHIELD # VM | OTHER | US9237053 | 01 | WA | AETNA PCP PIN VM | OTHER | 8493975 | 05 | WA | MEDICAID |