Healthcare Provider Details

I. General information

NPI: 1043261407
Provider Name (Legal Business Name): SALLY E MITCHELL M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/12/2006
Last Update Date: 10/11/2022
Certification Date: 10/11/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

501 6TH AVE S
ST PETERSBURG FL
33701-4634
US

IV. Provider business mailing address

PO BOX 64358
BALTIMORE MD
21264-4358
US

V. Phone/Fax

Practice location:
  • Phone: 727-767-3318
  • Fax:
Mailing address:
  • Phone: 410-550-2948
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2085R0204X
TaxonomyVascular & Interventional Radiology Physician
License NumberD26578
License Number StateMD
# 2
Primary TaxonomyY
Taxonomy Code2085R0204X
TaxonomyVascular & Interventional Radiology Physician
License NumberME151631
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: