Healthcare Provider Details

I. General information

NPI: 1508850694
Provider Name (Legal Business Name): IDOL RAY MITCHELL DPM
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/06/2005
Last Update Date: 05/15/2008
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 Number016-004683
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: