Provider Demographics
NPI:1013403088
Name:MIXON, SHUNDALE THOMAS (OD)
Entity Type:Individual
Prefix:
First Name:SHUNDALE
Middle Name:THOMAS
Last Name:MIXON
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1300 PEACHTREE INDUSTRIAL BLVD STE 1206
Mailing Address - Street 2:
Mailing Address - City:SUWANEE
Mailing Address - State:GA
Mailing Address - Zip Code:30024-4550
Mailing Address - Country:US
Mailing Address - Phone:770-783-2162
Mailing Address - Fax:770-783-2165
Practice Address - Street 1:1300 PEACHTREE INDUSTRIAL BLVD STE 1206
Practice Address - Street 2:
Practice Address - City:SUWANEE
Practice Address - State:GA
Practice Address - Zip Code:30024-4550
Practice Address - Country:US
Practice Address - Phone:334-318-0713
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-07-02
Last Update Date:2023-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAOPT003111152W00000X
GANA152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist