Provider Demographics
NPI:1639193246
Name:WIXTROM, KEITH ALLEN (MD)
Entity Type:Individual
Prefix:DR
First Name:KEITH
Middle Name:ALLEN
Last Name:WIXTROM
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
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Mailing Address - Street 1:308 HIDE A WAY LN C
Mailing Address - Street 2:
Mailing Address - City:HIDEAWAY
Mailing Address - State:TX
Mailing Address - Zip Code:75771-5202
Mailing Address - Country:US
Mailing Address - Phone:214-663-8244
Mailing Address - Fax:214-276-7333
Practice Address - Street 1:7916 S BROADWAY AVE
Practice Address - Street 2:
Practice Address - City:TYLER
Practice Address - State:TX
Practice Address - Zip Code:75703-5274
Practice Address - Country:US
Practice Address - Phone:903-266-5900
Practice Address - Fax:214-276-7333
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-27
Last Update Date:2019-04-24
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
TXG8515207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
B27640Medicare UPIN