Basic Information
Provider Information | |||||||||
NPI: | 1346250271 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | THOMAS M MIXA MD PA | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 5959 CENTRAL AVE | ||||||||
Address2: | SUITE 101 | ||||||||
City: | ST PETERSBURG | ||||||||
State: | FL | ||||||||
PostalCode: | 337108502 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7273219644 | ||||||||
FaxNumber: | 7273457415 | ||||||||
Practice Location | |||||||||
Address1: | 5959 CENTRAL AVE | ||||||||
Address2: | SUITE 101 | ||||||||
City: | ST PETERSBURG | ||||||||
State: | FL | ||||||||
PostalCode: | 337108502 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7273219644 | ||||||||
FaxNumber: | 7273457415 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 08/09/2006 | ||||||||
LastUpdateDate: | 06/04/2008 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | WATSON | ||||||||
AuthorizedOfficialFirstName: | KAREN | ||||||||
AuthorizedOfficialMiddleName: | N | ||||||||
AuthorizedOfficialTitleorPosition: | ACCOUNTS MANAGER | ||||||||
AuthorizedOfficialTelephone: | 7273219644 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207X00000X | ME0067156 | FL | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Orthopaedic Surgery |   |
ID Information
ID | Type | State | Issuer | Description | ME0067156 | 01 | FL | LICENSE | OTHER | BM1706994 | 01 | FL | DEA | OTHER | 376828700 | 05 | FL |   | MEDICAID |