Provider Demographics
NPI:1396805255
Name:MIXCO, ROBERTO (MD)
Entity type:Individual
Prefix:
First Name:ROBERTO
Middle Name:
Last Name:MIXCO
Suffix:
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 1:1395 N COURTENAY PKWY
Mailing Address - Street 2:STE 106
Mailing Address - City:MERRITT ISLAND
Mailing Address - State:FL
Mailing Address - Zip Code:32953-4474
Mailing Address - Country:US
Mailing Address - Phone:321-452-1224
Mailing Address - Fax:321-453-7784
Practice Address - Street 1:1395 N COURTENAY PKWY
Practice Address - Street 2:SUITE #106
Practice Address - City:MERRITT ISLAND
Practice Address - State:FL
Practice Address - Zip Code:32953-4400
Practice Address - Country:US
Practice Address - Phone:321-452-1224
Practice Address - Fax:321-453-7784
Is Sole Proprietor?:No
Enumeration Date:2006-12-11
Last Update Date:2025-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME 500632084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL591263223OtherCIGNA
FL051758500Medicaid
FL07492OtherBCBS
FL0623966OtherAETNA
FLD51934Medicare UPIN
FL051758500Medicaid