Provider Demographics
NPI:1942536024
Name:WIXOM, MICHAEL MATTHEW (IDMT)
Entity Type:Individual
Prefix:MR
First Name:MICHAEL
Middle Name:MATTHEW
Last Name:WIXOM
Suffix:
Gender:M
Credentials:IDMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PSC 80 BOX 20878
Mailing Address - Street 2:
Mailing Address - City:APO
Mailing Address - State:AP
Mailing Address - Zip Code:96367-0093
Mailing Address - Country:US
Mailing Address - Phone:319-208-7818
Mailing Address - Fax:
Practice Address - Street 1:PSC 80 BOX 20878
Practice Address - Street 2:
Practice Address - City:APO
Practice Address - State:AP
Practice Address - Zip Code:96367-0093
Practice Address - Country:US
Practice Address - Phone:319-208-7818
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-10-26
Last Update Date:2011-05-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1710I1003XOther Service ProvidersMilitary Health Care ProviderIndependent Duty Medical Technicians