Provider Demographics
NPI:1962430074
Name:MITCHELL, ELIZABETH WYATT (MD)
Entity type:Individual
Prefix:DR
First Name:ELIZABETH
Middle Name:WYATT
Last Name:MITCHELL
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:501 MARSHALL ST
Mailing Address - Street 2:SUITE 603
Mailing Address - City:JACKSON
Mailing Address - State:MS
Mailing Address - Zip Code:39202-1651
Mailing Address - Country:US
Mailing Address - Phone:601-352-6233
Mailing Address - Fax:601-985-9122
Practice Address - Street 1:501 MARSHALL ST
Practice Address - Street 2:SUITE 603
Practice Address - City:JACKSON
Practice Address - State:MS
Practice Address - Zip Code:39202-1651
Practice Address - Country:US
Practice Address - Phone:601-352-6233
Practice Address - Fax:601-985-9122
Is Sole Proprietor?:No
Enumeration Date:2006-06-29
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MS13902207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS331056270OtherBLUE CROSS PROVIDER NUMBE
MS00124327Medicaid
MS331056270OtherBLUE CROSS PROVIDER NUMBE
MS18000307Medicare ID - Type UnspecifiedMEDICARE PROVIDER NUMBER