Provider Demographics
NPI:1215938071
Name:HUEBNER, MITCHELL LEE (MD)
Entity type:Individual
Prefix:
First Name:MITCHELL
Middle Name:LEE
Last Name:HUEBNER
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 1:5477 GLEN LAKES DR STE 135
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75231-0977
Mailing Address - Country:US
Mailing Address - Phone:214-361-2277
Mailing Address - Fax:214-361-2273
Practice Address - Street 1:5477 GLEN LAKES DR STE 135
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75231-0977
Practice Address - Country:US
Practice Address - Phone:214-361-2277
Practice Address - Fax:214-361-2273
Is Sole Proprietor?:Yes
Enumeration Date:2005-08-02
Last Update Date:2020-10-23
Deactivation Date:2006-03-21
Deactivation Code:
Reactivation Date:2006-03-29
Provider Licenses
StateLicense IDTaxonomies
TXH8143207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX115151604Medicaid
TX115151606Medicaid
TX8S0455OtherBCBS
TX8S0455OtherBCBS
TX115151606Medicaid
TXP00421975Medicare PIN
TX8F20891Medicare PIN
TX115151604Medicaid