Healthcare Provider Details

I. General information

NPI: 1487641312
Provider Name (Legal Business Name): JAMES SAMUEL MITCHENER III MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/05/2005
Last Update Date: 11/20/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1414 FRANKLIN RD SW
ROANOKE VA
24016-5217
US

IV. Provider business mailing address

1414 FRANKLIN RD SW
ROANOKE VA
24016-5217
US

V. Phone/Fax

Practice location:
  • Phone: 540-985-0116
  • Fax: 540-985-0215
Mailing address:
  • Phone: 540-985-0116
  • Fax: 540-985-0215

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2086S0122X
TaxonomyPlastic and Reconstructive Surgery Physician
License Number0101034846
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: