Provider Demographics
NPI:1831282110
Name:ROBERTA A. MIX, D.O., P.A.
Entity Type:Organization
Organization Name:ROBERTA A. MIX, D.O., P.A.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:ROBERTA
Authorized Official - Middle Name:ANN
Authorized Official - Last Name:MIX
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:727-376-8885
Mailing Address - Street 1:2102 TRINITY OAKS BLVD
Mailing Address - Street 2:SUITE 201
Mailing Address - City:TRINITY
Mailing Address - State:FL
Mailing Address - Zip Code:34655-4409
Mailing Address - Country:US
Mailing Address - Phone:727-376-8885
Mailing Address - Fax:727-376-7997
Practice Address - Street 1:2102 TRINITY OAKS BLVD
Practice Address - Street 2:SUITE 201
Practice Address - City:TRINITY
Practice Address - State:FL
Practice Address - Zip Code:34655-4409
Practice Address - Country:US
Practice Address - Phone:727-376-8885
Practice Address - Fax:727-376-7997
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-01
Last Update Date:2012-11-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOS7532207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL2563461-00Medicaid
FL4867933001OtherDME
FL4867933001OtherDME
FLG99134Medicare UPIN