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General NPI Number Information
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NPI Number | 1962911438
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Entity Type | Organization
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Legal Business Name | MARK G MITCHELL OD A PROFESSIONAL CORPORATION
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Dates
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Enumeration Date | 09/27/2017
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Last Update Date | 09/27/2017
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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 |
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Provider Business Mailing Address
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Address Line | 2130 PRESIDIO WAY
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City | SAN MIGUEL
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State | CA
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Zip | 93451-9038
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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 | CEO
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Name | DR. MARK GLENN MITCHELL
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Credential | OD
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Telephone | 775-848-8214
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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 |
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License Number State |
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