Provider Demographics
NPI:1396365961
Name:OLDMIXON, JOHN MARTIN (LMT, BCTMB)
Entity Type:Individual
Prefix:MR
First Name:JOHN
Middle Name:MARTIN
Last Name:OLDMIXON
Suffix:
Gender:M
Credentials:LMT, BCTMB
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1717 W 34TH ST UNIT 600
Mailing Address - Street 2:
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77018-6264
Mailing Address - Country:US
Mailing Address - Phone:512-636-5953
Mailing Address - Fax:
Practice Address - Street 1:1919 NORTH LOOP W STE 445
Practice Address - Street 2:
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77008-1363
Practice Address - Country:US
Practice Address - Phone:832-703-8787
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-04-23
Last Update Date:2020-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXMT132768225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
2000268OtherNCBTMB
TXMT132768OtherTDLR