Provider Demographics
NPI:1821440231
Name:WIXON, RICHARD ERNEST JR
Entity Type:Individual
Prefix:MR
First Name:RICHARD
Middle Name:ERNEST
Last Name:WIXON
Suffix:JR
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1482 PREMIER VILLAGE WAY
Mailing Address - Street 2:
Mailing Address - City:CLEARWATER
Mailing Address - State:FL
Mailing Address - Zip Code:33764-2885
Mailing Address - Country:US
Mailing Address - Phone:727-643-7742
Mailing Address - Fax:
Practice Address - Street 1:1482 PREMIER VILLAGE WAY
Practice Address - Street 2:
Practice Address - City:CLEARWATER
Practice Address - State:FL
Practice Address - Zip Code:33764-2885
Practice Address - Country:US
Practice Address - Phone:727-643-7742
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-07-09
Last Update Date:2016-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker