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General NPI Number Information
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NPI Number | 1134124308
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Entity Type | Individual
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Provider Name | MARK GLENN MITCHELL O.D.
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Gender | Male
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Dates
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Enumeration Date | 06/15/2005
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Last Update Date | 06/11/2025
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Provider Practice Location Address
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Address Line | 678 E SANTA CLARA ST
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City | SAN JOSE
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State | CA
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Zip | 95112-1931
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Country | US
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Telephone | 408-293-2020
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Fax | 408-271-0225
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Provider Business Mailing Address
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Address Line | 2425 GOLDEN HILL STE 106-205
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City | PASO ROBLES
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State | CA
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Zip | 93446
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Country | US
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Telephone | 775-848-8214
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 152W00000X
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Taxonomy Name | Optometrist
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License Number | 8285T
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License Number State | CA
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