Provider Demographics
NPI:1144876806
Name:MITCHELL, DOMINIC T
Entity type:Individual
Prefix:
First Name:DOMINIC
Middle Name:T
Last Name:MITCHELL
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4626 KAVON AVE
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21206-5706
Mailing Address - Country:US
Mailing Address - Phone:443-759-4006
Mailing Address - Fax:443-203-2636
Practice Address - Street 1:4626 KAVON AVE
Practice Address - Street 2:
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21206-5706
Practice Address - Country:US
Practice Address - Phone:443-759-4006
Practice Address - Fax:443-203-2636
Is Sole Proprietor?:Yes
Enumeration Date:2019-08-17
Last Update Date:2019-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist