Healthcare Provider Details

I. General information

NPI: 1376543041
Provider Name (Legal Business Name): MITCHELL L WARREN M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/26/2005
Last Update Date: 09/04/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

740 WAUKEGAN RD SUITE 360
DEERFIELD IL
60015
US

IV. Provider business mailing address

740 WAUKEGAN RD SUITE 360
DEERFIELD IL
60015-4374
US

V. Phone/Fax

Practice location:
  • Phone: 847-945-6770
  • Fax: 847-945-3159
Mailing address:
  • Phone: 847-945-6770
  • Fax: 847-945-3159

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207W00000X
TaxonomyOphthalmology Physician
License Number036093327
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code207W00000X
TaxonomyOphthalmology Physician
License Number036-093327
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: