=====================================================
General NPI Number Information
=====================================================
NPI Number | 1508949355
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JOE R MITCHELL III O.D.
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/23/2006
-----------------------------------------------------
Last Update Date | 09/17/2015
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2681 C T SWITZER SR DR
-----------------------------------------------------
City | BILOXI
-----------------------------------------------------
State | MS
-----------------------------------------------------
Zip | 39531-4500
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 228-385-2681
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2558 CONIFER CT
-----------------------------------------------------
City | BILOXI
-----------------------------------------------------
State | MS
-----------------------------------------------------
Zip | 39531-2750
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 228-424-0507
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 152W00000X
-----------------------------------------------------
Taxonomy Name | Optometrist
-----------------------------------------------------
License Number | 565/94188
-----------------------------------------------------
License Number State | MS
-----------------------------------------------------