Healthcare Provider Details

I. General information

NPI: 1356072789
Provider Name (Legal Business Name): MITCHELL BRADY DO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/17/2022
Last Update Date: 09/24/2026
Certification Date: 09/24/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

166 A1A N STE 200
PONTE VEDRA BEACH FL
32082-5701
US

IV. Provider business mailing address

28050 GRAND RIVER AVE
FARMINGTON HILLS MI
48336-5919
US

V. Phone/Fax

Practice location:
  • Phone: 253-226-2798
  • Fax:
Mailing address:
  • Phone: 253-226-2798
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License NumberOS20596
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code207ND0101X
TaxonomyMOHS-Micrographic Surgery Physician
License NumberOS20596
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: