Provider Demographics
NPI:1982915195
Name:MIXON, TARISHA RENEE (MD)
Entity Type:Individual
Prefix:DR
First Name:TARISHA
Middle Name:RENEE
Last Name:MIXON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8490 PICARDY AVE
Mailing Address - Street 2:BLDG 200
Mailing Address - City:BATON ROUGE
Mailing Address - State:LA
Mailing Address - Zip Code:70809-3731
Mailing Address - Country:US
Mailing Address - Phone:225-237-1754
Mailing Address - Fax:225-237-1722
Practice Address - Street 1:3401 NORTH BLVD
Practice Address - Street 2:STE 200-A
Practice Address - City:BATON ROUGE
Practice Address - State:LA
Practice Address - Zip Code:70806-3743
Practice Address - Country:US
Practice Address - Phone:225-387-0851
Practice Address - Fax:225-383-8477
Is Sole Proprietor?:No
Enumeration Date:2010-06-23
Last Update Date:2014-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
LAMD.205942207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA295588YNB7OtherMEDICARE PTAN
LA2110454Medicaid