Provider Demographics
NPI:1538168315
Name:HUMPHREY, MITCHELL S (DO)
Entity type:Individual
Prefix:
First Name:MITCHELL
Middle Name:S
Last Name:HUMPHREY
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4950 BUFFALO RD
Mailing Address - Street 2:
Mailing Address - City:ERIE
Mailing Address - State:PA
Mailing Address - Zip Code:16510-2304
Mailing Address - Country:US
Mailing Address - Phone:814-899-7000
Mailing Address - Fax:814-899-0334
Practice Address - Street 1:4950 BUFFALO RD
Practice Address - Street 2:
Practice Address - City:ERIE
Practice Address - State:PA
Practice Address - Zip Code:16510-2304
Practice Address - Country:US
Practice Address - Phone:814-899-7000
Practice Address - Fax:814-899-0334
Is Sole Proprietor?:No
Enumeration Date:2005-07-14
Last Update Date:2020-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOS012331207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA01907892Medicaid
H71375Medicare UPIN
PA01907892Medicaid