Basic Information
| Provider Information | |||||||||
| NPI: | 1689634479 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MITCHELL | ||||||||
| FirstName: | MARK | ||||||||
| MiddleName: | EDWARD | ||||||||
| NamePrefix: | MR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2960 TONGASS AVENUE | ||||||||
| Address2: | |||||||||
| City: | KETCHIKAN | ||||||||
| State: | AK | ||||||||
| PostalCode: | 999015742 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9072284900 | ||||||||
| FaxNumber: | 8008523264 | ||||||||
| Practice Location | |||||||||
| Address1: | 2960 TONGASS AVENUE | ||||||||
| Address2: | |||||||||
| City: | KETCHIKAN | ||||||||
| State: | AK | ||||||||
| PostalCode: | 999015742 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9072284900 | ||||||||
| FaxNumber: | 8008523264 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/24/2006 | ||||||||
| LastUpdateDate: | 07/01/2016 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 2681761205 | UT | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 52588084 | 05 | NM | MEDICAID | 82071365 | 05 | CO | MEDICAID | D0289 | 05 | UT | MEDICAID | 314804 | 05 | AZ | MEDICAID |