Provider Demographics
NPI:1194175968
Name:MITCHELL, MAXIM (MD)
Entity type:Individual
Prefix:
First Name:MAXIM
Middle Name:
Last Name:MITCHELL
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3750 HEATHERWOOD DR APT B10
Mailing Address - Street 2:
Mailing Address - City:HAMBURG
Mailing Address - State:NY
Mailing Address - Zip Code:14075-2271
Mailing Address - Country:US
Mailing Address - Phone:701-780-6824
Mailing Address - Fax:701-780-4391
Practice Address - Street 1:3898 VINEYARD DR
Practice Address - Street 2:
Practice Address - City:DUNKIRK
Practice Address - State:NY
Practice Address - Zip Code:14048
Practice Address - Country:US
Practice Address - Phone:716-646-5500
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-06-13
Last Update Date:2019-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY299484207Q00000X
NDRL14088207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine