Individual
MR. EDWARD MITCHELL JR.
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
Man
Credential
LDO
Contact information
Practice address
4100 S FERDON BLVD STE B5, CRESTVIEW, FL 32536-5287
(850) 758-0474
(850) 682-0057
Mailing address
4100 S FERDON BLVD STE B5, CRESTVIEW, FL 32536-5287
(850) 758-0474
(850) 682-0057
Taxonomy
Speciality
Code
Description
License number
State
156FC0801X
Contact Lens Fitter
DO 5539
FL
156FX1800X
Optician
5539
FL
156FX1800X
Optician
DO 5539
FL
332H00000X
Eyewear Supplier
Primary
DO5539
FL
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
80-0442282
IRS
—
Enumeration date
03/28/2009
Last updated
10/15/2019
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