Provider Demographics
NPI:1578573846
Name:MIXDORF, TRACY M (DO)
Entity Type:Individual
Prefix:
First Name:TRACY
Middle Name:M
Last Name:MIXDORF
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
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Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:621 S ILLINOIS AVE
Mailing Address - Street 2:SUITE 103
Mailing Address - City:MASON CITY
Mailing Address - State:IA
Mailing Address - Zip Code:50401-5489
Mailing Address - Country:US
Mailing Address - Phone:641-428-3041
Mailing Address - Fax:641-428-3059
Practice Address - Street 1:1410 6TH AVE S
Practice Address - Street 2:
Practice Address - City:CLEAR LAKE
Practice Address - State:IA
Practice Address - Zip Code:50428-2606
Practice Address - Country:US
Practice Address - Phone:641-437-2191
Practice Address - Fax:641-657-6020
Is Sole Proprietor?:No
Enumeration Date:2006-08-09
Last Update Date:2020-07-28
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
IA03243207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IAH10357Medicare UPIN