Provider Demographics
NPI:1992783443
Name:MITCHELL, DARYL WINSTON (MD)
Entity type:Individual
Prefix:DR
First Name:DARYL
Middle Name:WINSTON
Last Name:MITCHELL
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 1:2508 BERT KOUNS LOOP
Mailing Address - Street 2:SUITE 401
Mailing Address - City:SHREVEPORT
Mailing Address - State:LA
Mailing Address - Zip Code:71118-3133
Mailing Address - Country:US
Mailing Address - Phone:318-686-5440
Mailing Address - Fax:318-686-0624
Practice Address - Street 1:2508 BERT KOUNS LOOP
Practice Address - Street 2:SUITE 401
Practice Address - City:SHREVEPORT
Practice Address - State:LA
Practice Address - Zip Code:71118-3133
Practice Address - Country:US
Practice Address - Phone:318-686-5440
Practice Address - Fax:318-686-0624
Is Sole Proprietor?:No
Enumeration Date:2006-01-05
Last Update Date:2024-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA07044R174400000X
LAMD.07044R207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
No174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1378071Medicaid
LA29416OtherBCBS OF LA
TX109244702Medicaid
TX8083TUOtherBCBS OF TX
LA1600009678Medicare ID - Type UnspecifiedRAILROAD MEDICARE
LA29416OtherBCBS OF LA