Provider Demographics
NPI:1841353943
Name:MITCHELL, LAURA H (OD)
Entity type:Individual
Prefix:
First Name:LAURA
Middle Name:H
Last Name:MITCHELL
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
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Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:6026 SAGAMORE LN
Mailing Address - Street 2:
Mailing Address - City:KALAMAZOO
Mailing Address - State:MI
Mailing Address - Zip Code:49004-8600
Mailing Address - Country:US
Mailing Address - Phone:269-373-1733
Mailing Address - Fax:
Practice Address - Street 1:6650 S WESTNEDGE AVE
Practice Address - Street 2:STE 232 CROSSROADS MALL
Practice Address - City:PORTAGE
Practice Address - State:MI
Practice Address - Zip Code:49024-3597
Practice Address - Country:US
Practice Address - Phone:269-327-2881
Practice Address - Fax:269-327-9253
Is Sole Proprietor?:No
Enumeration Date:2006-12-19
Last Update Date:2010-03-15
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MI4901003572152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIN34040054Medicare PIN
MIU33200Medicare UPIN