Healthcare Provider Details

I. General information

NPI: 1851484133
Provider Name (Legal Business Name): ROBERTA ANN MIX D.O.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/01/2006
Last Update Date: 08/19/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2102 TRINITY OAKS BLVD SUITE 201
TRINITY FL
34655-4409
US

IV. Provider business mailing address

4902 EISENHOWER BLVD SUITE 300
TAMPA FL
33634-6344
US

V. Phone/Fax

Practice location:
  • Phone: 727-376-8885
  • Fax: 727-376-7997
Mailing address:
  • Phone: 813-636-2000
  • Fax: 727-376-7997

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberOS7532
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: