Healthcare Provider Details

I. General information

NPI: 1376632851
Provider Name (Legal Business Name): LAURA J MITCHELL MD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/12/2006
Last Update Date: 09/01/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2305 GEORGIA ST
LOUISIANA MO
63353-2559
US

IV. Provider business mailing address

2305 GEORGIA ST
LOUISIANA MO
63353-2559
US

V. Phone/Fax

Practice location:
  • Phone: 573-754-5531
  • Fax: 573-754-6055
Mailing address:
  • Phone: 573-754-5531
  • Fax: 573-754-6055

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License NumberR6J75
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: