Provider Demographics
NPI:1447968425
Name:CORDLE, MITCHELL DUSTIN (CNIM)
Entity type:Individual
Prefix:
First Name:MITCHELL
Middle Name:DUSTIN
Last Name:CORDLE
Suffix:
Gender:M
Credentials:CNIM
Other - Prefix:
Other - First Name:MITCHELL
Other - Middle Name:DUSTIN
Other - Last Name:CORDLE
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:202 BRECKENRIDGE CT
Mailing Address - Street 2:
Mailing Address - City:CANTON
Mailing Address - State:GA
Mailing Address - Zip Code:30115-4317
Mailing Address - Country:US
Mailing Address - Phone:706-844-3984
Mailing Address - Fax:
Practice Address - Street 1:1200 NORTHSIDE FORSYTH DR
Practice Address - Street 2:
Practice Address - City:CUMMING
Practice Address - State:GA
Practice Address - Zip Code:30041-7659
Practice Address - Country:US
Practice Address - Phone:770-844-3200
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-11-09
Last Update Date:2022-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA2357156F00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156F00000XEye and Vision Services ProvidersTechnician/Technologist