Healthcare Provider Details

I. General information

NPI: 1801266051
Provider Name (Legal Business Name): DR. SANDRA MITCHUM
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/30/2015
Last Update Date: 09/30/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1701 COVEMEADOW DR
ARLINGTON TX
76012-5408
US

IV. Provider business mailing address

1701 COVEMEADOW DR
ARLINGTON TX
76012-5408
US

V. Phone/Fax

Practice location:
  • Phone: 214-729-0836
  • Fax: 817-795-1173
Mailing address:
  • Phone: 214-729-0836
  • Fax: 817-795-1173

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171W00000X
TaxonomyContractor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: