Provider Demographics
NPI:1962498683
Name:MIXON, TYNES EMERY III (MD)
Entity Type:Individual
Prefix:
First Name:TYNES
Middle Name:EMERY
Last Name:MIXON
Suffix:III
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
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
Is Sole Proprietor?:No
Enumeration Date:2005-09-27
Last Update Date:2013-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA020891207YX0905X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207YX0905XAllopathic & Osteopathic PhysiciansOtolaryngologyOtolaryngology/Facial Plastic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1680095Medicaid
LA5W801Medicare ID - Type Unspecified
LA1680095Medicaid