Provider Demographics
NPI:1720005754
Name:TYNES MIXON, III MD APMC
Entity Type:Organization
Organization Name:TYNES MIXON, III MD APMC
Other - Org Name:ENT OF ACADIANA
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:TYNES
Authorized Official - Middle Name:EMERY
Authorized Official - Last Name:MIXON
Authorized Official - Suffix:III
Authorized Official - Credentials:MD
Authorized Official - Phone:337-365-4156
Mailing Address - Street 1:426 CHARLES ST
Mailing Address - Street 2:
Mailing Address - City:NEW IBERIA
Mailing Address - State:LA
Mailing Address - Zip Code:70560-3707
Mailing Address - Country:US
Mailing Address - Phone:337-365-4156
Mailing Address - Fax:337-365-4192
Practice Address - Street 1:426 CHARLES ST
Practice Address - Street 2:
Practice Address - City:NEW IBERIA
Practice Address - State:LA
Practice Address - Zip Code:70560-3707
Practice Address - Country:US
Practice Address - Phone:337-365-4156
Practice Address - Fax:337-365-4192
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-16
Last Update Date:2008-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA207Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1445282Medicaid
LA1445282Medicaid