Provider Demographics
NPI:1750365276
Name:MIXON, JOHN W JR (OD)
Entity type:Individual
Prefix:
First Name:JOHN
Middle Name:W
Last Name:MIXON
Suffix:JR
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1119 E LAMAR ST
Mailing Address - Street 2:P O BOX 788
Mailing Address - City:AMERICUS
Mailing Address - State:GA
Mailing Address - Zip Code:31709-3762
Mailing Address - Country:US
Mailing Address - Phone:229-924-4022
Mailing Address - Fax:229-924-7133
Practice Address - Street 1:1119 E LAMAR ST
Practice Address - Street 2:
Practice Address - City:AMERICUS
Practice Address - State:GA
Practice Address - Zip Code:31709-3762
Practice Address - Country:US
Practice Address - Phone:229-924-4022
Practice Address - Fax:229-924-7133
Is Sole Proprietor?:No
Enumeration Date:2005-11-30
Last Update Date:2008-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAOPT002265152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA732994221AMedicaid
GA732994221CMedicaid
GA732994221BMedicaid
GA732994221CMedicaid
GA732994221BMedicaid
GAP00418542Medicare PIN
GA732994221AMedicaid