Provider Demographics
NPI:1679580526
Name:MITCHELL, ACCIE (MD)
Entity type:Individual
Prefix:
First Name:ACCIE
Middle Name:
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 1:19210 S VERMONT AVE
Mailing Address - Street 2:BLDG D, SUITE 400
Mailing Address - City:GARDENA
Mailing Address - State:CA
Mailing Address - Zip Code:90248-4426
Mailing Address - Country:US
Mailing Address - Phone:310-436-0202
Mailing Address - Fax:310-436-0202
Practice Address - Street 1:19210 S VERMONT AVE
Practice Address - Street 2:BLDG D, SUITE 400
Practice Address - City:GARDENA
Practice Address - State:CA
Practice Address - Zip Code:90248-4426
Practice Address - Country:US
Practice Address - Phone:310-436-0202
Practice Address - Fax:310-436-0202
Is Sole Proprietor?:No
Enumeration Date:2006-08-02
Last Update Date:2012-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAC28274208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00C282740Medicaid
CA00C282740Medicaid