Healthcare Provider Details

I. General information

NPI: 1003987173
Provider Name (Legal Business Name): IDOL R MITCHELL DPM PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/12/2006
Last Update Date: 06/30/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

437 EAST GRANT STREET
MACOMB IL
61455-3352
US

IV. Provider business mailing address

437 EAST GRANT STREET
MACOMB IL
61455-3352
US

V. Phone/Fax

Practice location:
  • Phone: 309-837-3964
  • Fax: 309-837-3966
Mailing address:
  • Phone: 309-837-3964
  • Fax: 309-837-3966

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code213E00000X
TaxonomyPodiatrist
License Number016004683
License Number StateIL

VIII. Authorized Official

Name: DR. IDOL R. MITCHELL
Title or Position: PRESIDENT
Credential:
Phone: 309-836-7900