Healthcare Provider Details

I. General information

NPI: 1316939895
Provider Name (Legal Business Name): LAURIE CLEMENS MITCHELL MD
Entity Type: Individual
Gender: Female
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 08/19/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

SOUTHERN INDIAN HEALTH COUCIL 4058 WILLOWS ROAD
ALPINE CA
91901
US

IV. Provider business mailing address

2865 ALATROSS ST
SAN DIEGO CA
92103
US

V. Phone/Fax

Practice location:
  • Phone: 619-445-1188
  • Fax:
Mailing address:
  • Phone: 619-260-0099
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberA55633
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: