Healthcare Provider Details

I. General information

NPI: 1790731230
Provider Name (Legal Business Name): MITCHELL DONGJUN IMM M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/26/2006
Last Update Date: 09/02/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10647 BRAMBLECREST DR
AUSTIN TX
78726-1906
US

IV. Provider business mailing address

10647 BRAMBLECREST DR
AUSTIN TX
78726-1906
US

V. Phone/Fax

Practice location:
  • Phone: 512-906-1974
  • Fax:
Mailing address:
  • Phone: 512-906-1974
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number200200707
License Number StateNC
# 2
Primary TaxonomyY
Taxonomy Code2080N0001X
TaxonomyNeonatal-Perinatal Medicine Physician
License Number200200707
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: