Provider Demographics
NPI:1093197204
Name:MIXAN, MARK (OD)
Entity Type:Individual
Prefix:DR
First Name:MARK
Middle Name:
Last Name:MIXAN
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12424 W DODGE RD STE 104
Mailing Address - Street 2:
Mailing Address - City:OMAHA
Mailing Address - State:NE
Mailing Address - Zip Code:68154-2322
Mailing Address - Country:US
Mailing Address - Phone:531-233-5680
Mailing Address - Fax:531-215-0937
Practice Address - Street 1:12424 W DODGE RD STE 104
Practice Address - Street 2:
Practice Address - City:OMAHA
Practice Address - State:NE
Practice Address - Zip Code:68154-2322
Practice Address - Country:US
Practice Address - Phone:531-233-5680
Practice Address - Fax:531-215-0937
Is Sole Proprietor?:No
Enumeration Date:2015-06-24
Last Update Date:2022-12-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA078291152W00000X
NE1461152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist