Basic Information
| Provider Information | |||||||||
| NPI: | 1811988751 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MITCHELL | ||||||||
| FirstName: | KELLY | ||||||||
| MiddleName: | T. | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 5865 | ||||||||
| Address2: | |||||||||
| City: | LUBBOCK | ||||||||
| State: | TX | ||||||||
| PostalCode: | 794085865 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8067432898 | ||||||||
| FaxNumber: | 8067432787 | ||||||||
| Practice Location | |||||||||
| Address1: | 3601 4TH ST | ||||||||
| Address2: | 2A100 | ||||||||
| City: | LUBBOCK | ||||||||
| State: | TX | ||||||||
| PostalCode: | 794300002 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8067432020 | ||||||||
| FaxNumber: | 8067431782 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/31/2005 | ||||||||
| LastUpdateDate: | 01/06/2014 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207W00000X | L1942 | TX | Y | Allopathic & Osteopathic Physicians | Ophthalmology |
ID Information
| ID | Type | State | Issuer | Description | 144792205 | 05 | TX | MEDICAID | 144792206 | 05 | TX | MEDICAID | 81940 | 05 | NM | MEDICAID | 200013870A | 05 | OK | MEDICAID | 87410Z | 01 | TX | HMO BLUE | OTHER | 08534730 | 05 | NM | MEDICAID | 8G7982 | 01 | TX | BC/BS | OTHER | 101449101 | 05 | TX | MEDICAID | 81940 | 01 | NM | PRESBYTERIAN COMMERCIAL | OTHER | A582 | 01 | NM | TRIWEST | OTHER | 101449100 | 01 | TX | FIRSTCARE COMMERCIAL | OTHER |