Provider Demographics
NPI:1770561904
Name:MITCHELL, MICHAEL ALLEN (DO)
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:ALLEN
Last Name:MITCHELL
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 1:100 S ARCHER
Mailing Address - Street 2:
Mailing Address - City:HENRIETTA
Mailing Address - State:TX
Mailing Address - Zip Code:76365
Mailing Address - Country:US
Mailing Address - Phone:940-538-0245
Mailing Address - Fax:940-538-0317
Practice Address - Street 1:100 S ARCHER
Practice Address - Street 2:
Practice Address - City:HENRIETTA
Practice Address - State:TX
Practice Address - Zip Code:76365
Practice Address - Country:US
Practice Address - Phone:940-538-0245
Practice Address - Fax:940-538-0317
Is Sole Proprietor?:No
Enumeration Date:2006-01-06
Last Update Date:2012-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXH9688207Q00000X, 207QG0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No207QG0300XAllopathic & Osteopathic PhysiciansFamily MedicineGeriatric Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX1362618-04Medicaid
TX1362618-04Medicaid