Provider Demographics
NPI:1952340168
Name:MIXON, FRED SMITH (MD)
Entity Type:Individual
Prefix:DR
First Name:FRED
Middle Name:SMITH
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:PO BOX 2699
Mailing Address - Street 2:
Mailing Address - City:PENSACOLA
Mailing Address - State:FL
Mailing Address - Zip Code:32513-2699
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:6665 PENSACOLA BLVD
Practice Address - Street 2:
Practice Address - City:PENSACOLA
Practice Address - State:FL
Practice Address - Zip Code:32505-1705
Practice Address - Country:US
Practice Address - Phone:850-416-2000
Practice Address - Fax:850-416-2080
Is Sole Proprietor?:No
Enumeration Date:2006-06-05
Last Update Date:2010-06-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME27034207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL065940100Medicaid
FL065940100Medicaid