Provider Demographics
NPI:1780614743
Name:MIX, GREGGORY ROBERT
Entity type:Individual
Prefix:
First Name:GREGGORY
Middle Name:ROBERT
Last Name:MIX
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1551 E TANGERINE RD
Mailing Address - Street 2:
Mailing Address - City:ORO VALLEY
Mailing Address - State:AZ
Mailing Address - Zip Code:85755-6213
Mailing Address - Country:US
Mailing Address - Phone:520-901-3500
Mailing Address - Fax:
Practice Address - Street 1:1551 E TANGERINE RD
Practice Address - Street 2:
Practice Address - City:ORO VALLEY
Practice Address - State:AZ
Practice Address - Zip Code:85755-6213
Practice Address - Country:US
Practice Address - Phone:520-901-3500
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-04
Last Update Date:2013-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ47662207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN817863100Medicaid
WI31722900Medicaid
AZ816355Medicaid
MN399000020Medicare ID - Type Unspecified
AZ816355Medicaid