Provider Demographics
NPI:1003806704
Name:MIX, ERIC W (DO)
Entity Type:Individual
Prefix:
First Name:ERIC
Middle Name:W
Last Name:MIX
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:LOCKBOX #17
Mailing Address - Street 2:2424 E. 21ST #100
Mailing Address - City:TULSA
Mailing Address - State:OK
Mailing Address - Zip Code:74114-1711
Mailing Address - Country:US
Mailing Address - Phone:866-321-8433
Mailing Address - Fax:
Practice Address - Street 1:300 ROCKEFELLER DR
Practice Address - Street 2:
Practice Address - City:MUSKOGEE
Practice Address - State:OK
Practice Address - Zip Code:74401-5075
Practice Address - Country:US
Practice Address - Phone:918-781-9466
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-10-24
Last Update Date:2009-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK4316207PE0004X, 207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No207PE0004XAllopathic & Osteopathic PhysiciansEmergency MedicineEmergency Medical Services