Provider Demographics
NPI:1164455267
Name:MIXON, GRADIE B JR (MD)
Entity Type:Individual
Prefix:
First Name:GRADIE
Middle Name:B
Last Name:MIXON
Suffix:JR
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:604 CHERRY HILL CT
Mailing Address - Street 2:
Mailing Address - City:MODESTO
Mailing Address - State:CA
Mailing Address - Zip Code:95356-9556
Mailing Address - Country:US
Mailing Address - Phone:209-522-9566
Mailing Address - Fax:
Practice Address - Street 1:4601 DALE ROAD
Practice Address - Street 2:
Practice Address - City:MODESTO
Practice Address - State:CA
Practice Address - Zip Code:95356
Practice Address - Country:US
Practice Address - Phone:209-735-5000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-09
Last Update Date:2022-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG57069207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G570690Medicare ID - Type Unspecified