Healthcare Provider Details

I. General information

NPI: 1255918462
Provider Name (Legal Business Name): MATTHEW ROBERT MITCHELL MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/24/2021
Last Update Date: 08/04/2026
Certification Date: 08/04/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3549 N UNIVERSITY AVE
PROVO UT
84604-4487
US

IV. Provider business mailing address

3549 N UNIVERSITY AVE
PROVO UT
84604-4487
US

V. Phone/Fax

Practice location:
  • Phone: 385-284-7615
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number14283532-1205
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: