Provider Demographics
NPI:1326209859
Name:ROBERT D. MIXSON MD PA A GEORGIA CORP
Entity Type:Organization
Organization Name:ROBERT D. MIXSON MD PA A GEORGIA CORP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:DAVID
Authorized Official - Last Name:MIXSON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:912-882-7100
Mailing Address - Street 1:104 LAKESHORE DR
Mailing Address - Street 2:STE A
Mailing Address - City:SAINT MARYS
Mailing Address - State:GA
Mailing Address - Zip Code:31558-3803
Mailing Address - Country:US
Mailing Address - Phone:912-882-7100
Mailing Address - Fax:912-882-9149
Practice Address - Street 1:104 LAKESHORE DR
Practice Address - Street 2:STE A
Practice Address - City:SAINT MARYS
Practice Address - State:GA
Practice Address - Zip Code:31558-3803
Practice Address - Country:US
Practice Address - Phone:912-882-7100
Practice Address - Fax:912-882-9149
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-06-18
Last Update Date:2013-12-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA39415207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000643431AMedicaid
GA000643431AMedicaid