=====================================================
General NPI Number Information
=====================================================
NPI Number | 1477542850
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | KENNETH PAUL MITCHELL MD
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/18/2005
-----------------------------------------------------
Last Update Date | 01/12/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2600 PARTIN DR N STE 110
-----------------------------------------------------
City | NICEVILLE
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32578-1543
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 850-517-6578
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 910 ROYCE ST
-----------------------------------------------------
City | PENSACOLA
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32503-2464
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 850-444-4997
-----------------------------------------------------
Fax | 850-444-4992
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207VG0400X
-----------------------------------------------------
Taxonomy Name | Gynecology Physician
-----------------------------------------------------
License Number | ME48856
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 207QB0002X
-----------------------------------------------------
Taxonomy Name | Obesity Medicine (Family Medicine) Physician
-----------------------------------------------------
License Number | ME48856
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------