Provider Demographics
NPI:1629357868
Name:MICHAEL D MIXON MDPA
Entity Type:Organization
Organization Name:MICHAEL D MIXON MDPA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:D
Authorized Official - Last Name:MIXON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:214-703-3764
Mailing Address - Street 1:PO BOX 941
Mailing Address - Street 2:
Mailing Address - City:WYLIE
Mailing Address - State:TX
Mailing Address - Zip Code:75098-0941
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1213 DARTMOUTH CIR
Practice Address - Street 2:
Practice Address - City:MURPHY
Practice Address - State:TX
Practice Address - Zip Code:75094-4112
Practice Address - Country:US
Practice Address - Phone:214-703-3764
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-08-05
Last Update Date:2012-04-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXJ1317207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX098970901Medicaid
TX098970901Medicaid
TX00J87GMedicare PIN