Provider Demographics
NPI:1851484133
Name:MIX, ROBERTA ANN (DO)
Entity Type:Individual
Prefix:DR
First Name:ROBERTA
Middle Name:ANN
Last Name:MIX
Suffix:
Gender:F
Credentials:DO
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Mailing Address - Street 1:4902 EISENHOWER BLVD
Mailing Address - Street 2:SUITE 300
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33634-6344
Mailing Address - Country:US
Mailing Address - Phone:813-636-2000
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
Is Sole Proprietor?:No
Enumeration Date:2006-10-01
Last Update Date:2014-08-19
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Provider Licenses
StateLicense IDTaxonomies
FLOS7532207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL080147946OtherRAILROAD MEDICARE
FL011909200Medicaid
FL44833Medicare PIN
FL011909200Medicaid
FL080147946OtherRAILROAD MEDICARE