Provider Demographics
NPI:1144379777
Name:MITCHELL, CHARLES R (OD)
Entity type:Individual
Prefix:DR
First Name:CHARLES
Middle Name:R
Last Name:MITCHELL
Suffix:
Gender:M
Credentials:OD
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Mailing Address - Street 1:2101 E JEFFERSON ST
Mailing Address - Street 2:KAISER PERMANENTE, PPQA, 6 WEST, ATTN: THERESA BROOKS
Mailing Address - City:ROCKVILLE
Mailing Address - State:MD
Mailing Address - Zip Code:20852-4908
Mailing Address - Country:US
Mailing Address - Phone:301-816-6660
Mailing Address - Fax:301-816-6308
Practice Address - Street 1:10810 CONNECTICUT AVE
Practice Address - Street 2:
Practice Address - City:KENSINGTON
Practice Address - State:MD
Practice Address - Zip Code:20895-2138
Practice Address - Country:US
Practice Address - Phone:301-929-7507
Practice Address - Fax:301-929-7114
Is Sole Proprietor?:No
Enumeration Date:2007-01-10
Last Update Date:2024-05-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDDA1366152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
016515K92Medicare ID - Type Unspecified
U36312Medicare UPIN