Individual
IDOL RAY MITCHELL
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
Man
Credential
DPM
Contact information
Practice address
437 EAST GRANT STREET, MACOMB, IL 61455-3352
(309) 837-3964
(309) 837-3966
Mailing address
437 EAST GRANT STREET, MACOMB, IL 61455-3352
(309) 837-3964
(309) 837-3966
Taxonomy
Speciality
Code
Description
License number
State
213E00000X
Podiatrist
Primary
016-004683
IL
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
016004683
—
IL
01
—
214428
MEDICARE ID
IL
01
—
4452210001
DMERC
—
01
—
480034728
RAILROAD MEDICARE PROV #
—
Enumeration date
09/06/2005
Last updated
05/15/2008
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