Healthcare Provider Details

I. General information

NPI: 1396805255
Provider Name (Legal Business Name): ROBERTO MIXCO MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/11/2006
Last Update Date: 01/10/2025
Certification Date: 01/10/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1395 N COURTENAY PKWY SUITE #106
MERRITT ISLAND FL
32953-4400
US

IV. Provider business mailing address

1395 N COURTENAY PKWY STE 106
MERRITT ISLAND FL
32953-4474
US

V. Phone/Fax

Practice location:
  • Phone: 321-452-1224
  • Fax: 321-453-7784
Mailing address:
  • Phone: 321-452-1224
  • Fax: 321-453-7784

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084N0400X
TaxonomyNeurology Physician
License NumberME 50063
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: