=====================================================
General NPI Number Information
=====================================================
NPI Number | 1154561033
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | DAVID S MITCHELL DO PA
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/04/2009
-----------------------------------------------------
Last Update Date | 04/21/2009
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1255 ROUTE 70 STE 20N
-----------------------------------------------------
City | LAKEWOOD
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 08701-6192
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 732-905-8333
-----------------------------------------------------
Fax | 732-905-8709
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1255 ROUTE 70 STE 20N
-----------------------------------------------------
City | LAKEWOOD
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 08701-6192
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 732-905-8333
-----------------------------------------------------
Fax | 732-905-8709
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | DR. DAVID STUART MITCHELL
-----------------------------------------------------
Credential | D.O.
-----------------------------------------------------
Telephone | 732-905-8333
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207R00000X
-----------------------------------------------------
Taxonomy Name | Internal Medicine Physician
-----------------------------------------------------
License Number | MB55269
-----------------------------------------------------
License Number State | NJ
-----------------------------------------------------