Healthcare Provider Details

I. General information

NPI: 1922082197
Provider Name (Legal Business Name): MICHAEL D MITCHELL M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/01/2005
Last Update Date: 04/03/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

51 GLASGOW AVE.
JAMESTOWN NY
14701
US

IV. Provider business mailing address

5945 DAMON HILL RD
SINCLAIRVILLE NY
14782-9728
US

V. Phone/Fax

Practice location:
  • Phone: 716-664-8604
  • Fax:
Mailing address:
  • Phone: 716-397-0814
  • Fax: 716-338-1575

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2081S0010X
TaxonomySports Medicine (Physical Medicine & Rehabilitation) Physician
License Number162887
License Number StateNY
# 2
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number162887
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: