MEDICARE: DR. STEPHEN WILFRED MITCHELL M.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	171000000X	Military Health Care Provider
2	207Q00000X	Family Medicine Physician	040163	GA

General Provider Information

NPI Number	:	1598732760
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. STEPHEN WILFRED MITCHELL M.D.

Provider Business Mailing Address
First Line	:	1100 WILFORD HALL LOOP
Second Line	:
City	:	JBSA LACKLAND
State	:	TX
Zip	:	78236-5638
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	1100 WILFORD HALL LOOP BLDG 4554
Second Line	:
City	:	SAN ANTONIO
State	:	TX
Zip	:	78236-5638
Country	:	US
Telephone Number	:	210-292-3255
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	03/07/2006
Last Update Date	:	08/05/2020

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