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General NPI Number Information
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NPI Number | 1336174598
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Entity Type | Individual
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Provider Name | MITCHELL E F TRAVIS MD
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Gender | Male
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Dates
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Enumeration Date | 07/12/2006
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Last Update Date | 03/05/2021
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Provider Practice Location Address
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Address Line | 10517 MAPLE SPRINGS CV
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City | FORT WAYNE
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State | IN
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Zip | 46845-2132
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Country | US
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Telephone | 952-595-1100
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Fax | 612-294-4903
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Provider Business Mailing Address
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Address Line | 3707 NEW VISION DR
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City | FORT WAYNE
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State | IN
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Zip | 46845-1702
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Country | US
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Telephone | 260-373-4731
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Fax | 612-294-4903
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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 | 2085R0202X
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Taxonomy Name | Diagnostic Radiology Physician
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License Number | MD60447306
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License Number State | WA
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Taxonomy #2
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Taxonomy Code | 2085R0202X
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Taxonomy Name | Diagnostic Radiology Physician
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License Number | 01043985
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License Number State | IN
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Taxonomy #3
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Taxonomy Code | 2085R0202X
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Taxonomy Name | Diagnostic Radiology Physician
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License Number | 1876
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License Number State | MN
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Taxonomy #4
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Taxonomy Code | 2085R0202X
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Taxonomy Name | Diagnostic Radiology Physician
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License Number | 51163
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License Number State | TN
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