Provider Demographics
NPI:1225086077
Name:LOFTIN, MITCHELL M (OD)
Entity type:Individual
Prefix:
First Name:MITCHELL
Middle Name:M
Last Name:LOFTIN
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 896189
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28289-6189
Mailing Address - Country:US
Mailing Address - Phone:864-654-6706
Mailing Address - Fax:
Practice Address - Street 1:322 UNION STATION DR
Practice Address - Street 2:
Practice Address - City:SENECA
Practice Address - State:SC
Practice Address - Zip Code:29678-4547
Practice Address - Country:US
Practice Address - Phone:864-654-6706
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-05-04
Last Update Date:2024-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MOODT03245152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO318015401Medicaid
MO410029705OtherRR MEDICARE
MO318015401Medicaid
MO410029705OtherRR MEDICARE