Provider Demographics
NPI:1518432962
Name:MIXON, ANTONIO
Entity Type:Individual
Prefix:
First Name:ANTONIO
Middle Name:
Last Name:MIXON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1405 SPRUCE ST STE A
Mailing Address - Street 2:
Mailing Address - City:RIVERSIDE
Mailing Address - State:CA
Mailing Address - Zip Code:92507-2410
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1405 SPRUCE STREET
Practice Address - Street 2:SUITE A
Practice Address - City:RIVERSIDE
Practice Address - State:CA
Practice Address - Zip Code:92507
Practice Address - Country:US
Practice Address - Phone:951-715-5050
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-10-11
Last Update Date:2018-10-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1744P3200XOther Service ProvidersSpecialistProsthetics Case Management