Provider Demographics
NPI:1316928138
Name:MITCHELL, KYLE DARREN (DO)
Entity type:Individual
Prefix:
First Name:KYLE
Middle Name:DARREN
Last Name:MITCHELL
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15876 MEADOW KING COURT
Mailing Address - Street 2:
Mailing Address - City:ALPHARETTA
Mailing Address - State:GA
Mailing Address - Zip Code:30004
Mailing Address - Country:US
Mailing Address - Phone:678-571-7684
Mailing Address - Fax:770-421-8096
Practice Address - Street 1:1455 BELLS FERRY ROAD
Practice Address - Street 2:SUITE 100
Practice Address - City:MARIETTA
Practice Address - State:GA
Practice Address - Zip Code:30066
Practice Address - Country:US
Practice Address - Phone:770-421-8094
Practice Address - Fax:770-421-8096
Is Sole Proprietor?:No
Enumeration Date:2005-11-09
Last Update Date:2023-03-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA051689207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000967843EMedicaid
GA000967843IMedicaid
GA202I085520Medicare PIN
GA000967843IMedicaid