Provider Demographics
NPI:1679667091
Name:MITCHELL, BRADFORD KENT (MD)
Entity type:Individual
Prefix:DR
First Name:BRADFORD
Middle Name:KENT
Last Name:MITCHELL
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:640 S. STATE STREET
Mailing Address - Street 2:MAIL CODE 3055
Mailing Address - City:DOVER
Mailing Address - State:DE
Mailing Address - Zip Code:19901-3530
Mailing Address - Country:US
Mailing Address - Phone:302-480-1688
Mailing Address - Fax:302-480-9807
Practice Address - Street 1:4660 S. HAGADORN ROAD
Practice Address - Street 2:SUITE 600
Practice Address - City:EAST LANSING
Practice Address - State:MI
Practice Address - Zip Code:48823
Practice Address - Country:US
Practice Address - Phone:517-267-2460
Practice Address - Fax:517-267-2462
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-02
Last Update Date:2021-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DEC1-0023939208600000X
WV204822086X0206X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Single Specialty
No2086X0206XAllopathic & Osteopathic PhysiciansSurgerySurgical Oncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV0126711000Medicaid
MI1679667091Medicaid
WVMI6030331Medicare ID - Type Unspecified
MI0C3608813Medicare PIN
WV0126711000Medicaid