Provider Demographics
NPI:1174564538
Name:MARK C MITCHUM OD
Entity type:Organization
Organization Name:MARK C MITCHUM OD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:MARK
Authorized Official - Middle Name:CHANDLER
Authorized Official - Last Name:MITCHUM
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:919-775-5221
Mailing Address - Street 1:2648 LEE AVENUE
Mailing Address - Street 2:
Mailing Address - City:SANFORD
Mailing Address - State:NC
Mailing Address - Zip Code:27332-5950
Mailing Address - Country:US
Mailing Address - Phone:919-775-5221
Mailing Address - Fax:919-775-7655
Practice Address - Street 1:2648 LEE AVENUE
Practice Address - Street 2:
Practice Address - City:SANFORD
Practice Address - State:NC
Practice Address - Zip Code:27332-5950
Practice Address - Country:US
Practice Address - Phone:919-775-5221
Practice Address - Fax:919-775-7655
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-09
Last Update Date:2008-03-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC1270152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC093N1OtherBCBSNC
NC89093N1Medicaid