Provider Demographics
NPI:1710969704
Name:MIXON, WILLIAM ALFRED (MD)
Entity Type:Individual
Prefix:DR
First Name:WILLIAM
Middle Name:ALFRED
Last Name:MIXON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:DR
Other - First Name:WILLIAM
Other - Middle Name:ALFRED
Other - Last Name:MIXON
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:1717 OAK PARK BLVD
Mailing Address - Street 2:SUITE 1
Mailing Address - City:LAKE CHARLES
Mailing Address - State:LA
Mailing Address - Zip Code:70601-8991
Mailing Address - Country:US
Mailing Address - Phone:337-478-3810
Mailing Address - Fax:337-478-6360
Practice Address - Street 1:1717 OAK PARK BLVD
Practice Address - Street 2:SUITE 1
Practice Address - City:LAKE CHARLES
Practice Address - State:LA
Practice Address - Zip Code:70601-8991
Practice Address - Country:US
Practice Address - Phone:337-478-3810
Practice Address - Fax:337-478-6360
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-11-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA09373174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1112437Medicaid
LA5846182OtherAETNA
LA5339Medicare ID - Type Unspecified
LAB64585Medicare UPIN