Healthcare Provider Details

I. General information

NPI: 1225086077
Provider Name (Legal Business Name): MITCHELL M LOFTIN OD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/04/2006
Last Update Date: 10/09/2024
Certification Date: 10/09/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

322 UNION STATION DR
SENECA SC
29678-4547
US

IV. Provider business mailing address

PO BOX 896189
CHARLOTTE NC
28289-6189
US

V. Phone/Fax

Practice location:
  • Phone: 864-654-6706
  • Fax:
Mailing address:
  • Phone: 864-654-6706
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License NumberODT03245
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: