Healthcare Provider Details

I. General information

NPI: 1497958508
Provider Name (Legal Business Name): WILLIAM A. MITCHELL III M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/06/2007
Last Update Date: 01/27/2021
Certification Date: 01/27/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1225 S GRAND BLVD
SAINT LOUIS MO
63104-1016
US

IV. Provider business mailing address

1225 S GRAND BLVD
SAINT LOUIS MO
63104-1016
US

V. Phone/Fax

Practice location:
  • Phone: 314-257-3390
  • Fax:
Mailing address:
  • Phone: 314-257-3390
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207QS0010X
TaxonomySports Medicine (Family Medicine) Physician
License Number2006009461
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: