Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 156FX1700X | Ocularist |
NPI | 1073549226 |
---|---|
Provider Name | Mitchell J Mayo |
First Address | Colorado Springs, CO 80918-1451 |
Second Address | Colorado Springs, CO 80918-1451 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 22/06/2006 |
Last Update Date | 10/02/2020 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
07137214 | (05) | CO |
364478259 | TRICARE (01) |