Healthcare Provider Details

I. General information

NPI: 1588045017
Provider Name (Legal Business Name): CALEB J MITCHELL D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/10/2015
Last Update Date: 07/20/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1340 IL HIGHWAY 1 STE E
CARMI IL
62821
US

IV. Provider business mailing address

1201 PINE ST
ELDORADO IL
62930-1634
US

V. Phone/Fax

Practice location:
  • Phone: 618-380-9321
  • Fax: 618-273-2504
Mailing address:
  • Phone: 618-273-3361
  • Fax: 618-273-2504

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number036146015
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number11018326A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: