Healthcare Provider Details

I. General information

NPI: 1164955761
Provider Name (Legal Business Name): MATTHEW MITCHELL MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/10/2017
Last Update Date: 06/10/2026
Certification Date: 06/10/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

304 ASHOURIAN AVE STE 107
SAINT AUGUSTINE FL
32092-5110
US

IV. Provider business mailing address

304 ASHOURIAN AVE STE 107
SAINT AUGUSTINE FL
32092-5110
US

V. Phone/Fax

Practice location:
  • Phone: 904-657-4103
  • Fax:
Mailing address:
  • Phone: 904-657-4103
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2086S0122X
TaxonomyPlastic and Reconstructive Surgery Physician
License NumberME159355
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: