Basic Information
| Provider Information | |||||||||
| NPI: | 1366837718 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MITCHELL | ||||||||
| FirstName: | KEVIN | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MBBS | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3525 E LOUISE DR STE 195 | ||||||||
| Address2: | |||||||||
| City: | MERIDIAN | ||||||||
| State: | ID | ||||||||
| PostalCode: | 836426303 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2088468335 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 3525 E LOUISE DR STE 195 | ||||||||
| Address2: | |||||||||
| City: | MERIDIAN | ||||||||
| State: | ID | ||||||||
| PostalCode: | 836426303 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2088468335 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/02/2015 | ||||||||
| LastUpdateDate: | 12/13/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 12/13/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RN0300X | M-16029 | ID | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Nephrology |
No ID Information.