Basic Information
| Provider Information | |||||||||
| NPI: | 1609969807 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MIXTER -LEON | ||||||||
| FirstName: | INGRID | ||||||||
| MiddleName: | M. | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | MIXTER PEDERSEN | ||||||||
| OtherFirstName: | INGRID | ||||||||
| OtherMiddleName: | M. | ||||||||
| OtherNamePrefix: | DR. | ||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | M.D. | ||||||||
| OtherLastNameType: | 5 | ||||||||
| Mailing Information | |||||||||
| Address1: | 101 SW 27TH AVE | ||||||||
| Address2: | |||||||||
| City: | MIAMI | ||||||||
| State: | FL | ||||||||
| PostalCode: | 331351428 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3056425366 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 101 SW 27TH AVE | ||||||||
| Address2: | |||||||||
| City: | MIAMI | ||||||||
| State: | FL | ||||||||
| PostalCode: | 331351428 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3056425366 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/02/2006 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
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| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 172A00000X | M236413578840 | FL | X | Other Service Providers | Driver | 207Q00000X | ME96827 | FL | X | Allopathic & Osteopathic Physicians | Family Medicine |
No ID Information.