Healthcare Provider Details

I. General information

NPI: 1386384980
Provider Name (Legal Business Name): MITCHELL THOMAS DO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/31/2022
Last Update Date: 07/09/2026
Certification Date: 07/09/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1409 KINGSLEY AVE STE 8
ORANGE PARK FL
32073-4553
US

IV. Provider business mailing address

1409 KINGSLEY AVE STE 8
ORANGE PARK FL
32073-4553
US

V. Phone/Fax

Practice location:
  • Phone: 904-269-7200
  • Fax: 904-269-0700
Mailing address:
  • Phone: 904-269-7200
  • Fax: 904-269-0700

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License NumberOS21595
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: