Provider Demographics
NPI:1801900709
Name:MIXON, HENRY TERRELL (MD)
Entity type:Individual
Prefix:
First Name:HENRY
Middle Name:TERRELL
Last Name:MIXON
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 1:1830 S HAWTHORNE ROAD
Mailing Address - Street 2:
Mailing Address - City:WINSTON-SALEM
Mailing Address - State:NC
Mailing Address - Zip Code:27103-4047
Mailing Address - Country:US
Mailing Address - Phone:336-448-2427
Mailing Address - Fax:336-765-2869
Practice Address - Street 1:1830 S HAWTHORNE ROAD
Practice Address - Street 2:
Practice Address - City:WINSTON-SALEM
Practice Address - State:NC
Practice Address - Zip Code:27103-4047
Practice Address - Country:US
Practice Address - Phone:336-448-2427
Practice Address - Fax:336-765-2869
Is Sole Proprietor?:No
Enumeration Date:2006-08-18
Last Update Date:2020-12-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC34106207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC89-59816Medicaid
2900766OtherUNITED HEALTHCARE
59816OtherBLUE CROSS BLUE SHIELD
E95458Medicare UPIN
NC89-59816Medicaid