Healthcare Provider Details

I. General information

NPI: 1295717940
Provider Name (Legal Business Name): BILLY J MITCHELL JR. O.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/17/2005
Last Update Date: 01/13/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

668 FALLS BLVD N
WYNNE AR
72396-2614
US

IV. Provider business mailing address

668 FALLS BLVD N
WYNNE AR
72396-2614
US

V. Phone/Fax

Practice location:
  • Phone: 870-238-3535
  • Fax: 870-238-2427
Mailing address:
  • Phone: 870-238-3535
  • Fax: 870-238-2427

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License NumberAR2426
License Number StateAR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: