Provider Demographics
NPI:1194168807
Name:MITCHELL, MICHAEL SHANE (IDC)
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:SHANE
Last Name:MITCHELL
Suffix:
Gender:M
Credentials:IDC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5371 WASHINGTON ST
Mailing Address - Street 2:
Mailing Address - City:CAMP LEJEUNE
Mailing Address - State:NC
Mailing Address - Zip Code:28547-1104
Mailing Address - Country:US
Mailing Address - Phone:843-640-2075
Mailing Address - Fax:
Practice Address - Street 1:5371 WASHINGTON ST
Practice Address - Street 2:
Practice Address - City:CAMP LEJEUNE
Practice Address - State:NC
Practice Address - Zip Code:28547-1104
Practice Address - Country:US
Practice Address - Phone:843-640-2075
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-04-11
Last Update Date:2013-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1710I1002XOther Service ProvidersMilitary Health Care ProviderIndependent Duty Corpsman