Basic Information
| Provider Information | |||||||||
| NPI: | 1760473102 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MITCHELL | ||||||||
| FirstName: | LARRY | ||||||||
| MiddleName: | GILMER | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | P.O. BOX CVPA | ||||||||
| Address2: | |||||||||
| City: | RICHLANDS | ||||||||
| State: | VI | ||||||||
| PostalCode: | 24641 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2769646771 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 1 CLINIC DR | ||||||||
| Address2: | CLAYPOOL HILL | ||||||||
| City: | RICHLANDS | ||||||||
| State: | VA | ||||||||
| PostalCode: | 246411100 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2769646771 | ||||||||
| FaxNumber: | 2769641321 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/03/2005 | ||||||||
| LastUpdateDate: | 03/29/2019 | ||||||||
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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 | 0101033360 | VA | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 0053207-000 | 05 | WV | MEDICAID | 002655 | 01 | ANTHEM BCBS | OTHER | 5636264 | 05 | VA | MEDICAID | 64666670 | 05 | KY | MEDICAID |