1386684405 NPI number — JONATHAN CHRISTOPHER MITCHELL MD

Table of content: JONATHAN CHRISTOPHER MITCHELL MD (NPI 1386684405)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1386684405 NPI number — JONATHAN CHRISTOPHER MITCHELL MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MITCHELL
Provider First Name:
JONATHAN
Provider Middle Name:
CHRISTOPHER
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1386684405
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
12/07/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 40
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
PUYALLUP
Provider Business Mailing Address State Name:
WA
Provider Business Mailing Address Postal Code:
98371-0137
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
253-697-5502
Provider Business Mailing Address Fax Number:
253-697-5510

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
11102 SUNRISE BLVD E
Provider Second Line Business Practice Location Address:
SUITE 110
Provider Business Practice Location Address City Name:
PUYALLUP
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
98374-8846
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
253-697-7350
Provider Business Practice Location Address Fax Number:
253-841-5962
Provider Enumeration Date:
06/07/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 207V00000X , with the licence number:  MD00041368 , registered in the state of WA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 0141390 . This is a "L & I PROVIDER NUMBER" identifier , issued by the state of ( WA ) . This identifiers is of the category "OTHER".
  • Identifier: 1121MI . This is a "REGENCE RIDER NUMBER" identifier , issued by the state of ( WA ) . This identifiers is of the category "OTHER".
  • Identifier: 7699536 . This is a "AETNA PROVIDER NUMBER" identifier , issued by the state of ( WA ) . This identifiers is of the category "OTHER".
  • Identifier: 8316432 , issued by the state of ( WA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 911203494BX . This is a "KPS PROVIDER NUMBER" identifier , issued by the state of ( WA ) . This identifiers is of the category "OTHER".
  • Identifier: 98375E004 . This is a "TRICARE PROVIDER NUMBER" identifier , issued by the state of ( WA ) . This identifiers is of the category "OTHER".




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