Healthcare Provider Details

I. General information

NPI: 1982853149
Provider Name (Legal Business Name): ANDREA JO MITCHELL O.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/11/2008
Last Update Date: 02/21/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

270 E COURT AVE
SELMER TN
38375-2304
US

IV. Provider business mailing address

699 E POPLAR AVE
SELMER TN
38375-1828
US

V. Phone/Fax

Practice location:
  • Phone: 731-645-7932
  • Fax:
Mailing address:
  • Phone: 731-434-3401
  • Fax: 731-434-3403

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number2820
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: