Provider Demographics
NPI:1609969807
Name:MIXTER -LEON, INGRID M (MD)
Entity Type:Individual
Prefix:
First Name:INGRID
Middle Name:M
Last Name:MIXTER -LEON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:DR
Other - First Name:INGRID
Other - Middle Name:M
Other - Last Name:MIXTER PEDERSEN
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:101 SW 27TH AVE
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33135-1428
Mailing Address - Country:US
Mailing Address - Phone:305-642-5366
Mailing Address - Fax:
Practice Address - Street 1:101 SW 27TH AVE
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33135-1428
Practice Address - Country:US
Practice Address - Phone:305-642-5366
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLM236413578840172A00000X
FLME96827207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered172A00000XOther Service ProvidersDriver
Not Answered207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine