Healthcare Provider Details

I. General information

NPI: 1962498683
Provider Name (Legal Business Name): TYNES EMERY MIXON III MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/27/2005
Last Update Date: 09/09/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

426 CHARLES ST
NEW IBERIA LA
70560-3707
US

IV. Provider business mailing address

426 CHARLES ST
NEW IBERIA LA
70560-3707
US

V. Phone/Fax

Practice location:
  • Phone: 337-365-4156
  • Fax: 337-365-4192
Mailing address:
  • Phone: 337-365-4156
  • Fax: 337-365-4192

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207YX0905X
TaxonomyOtolaryngology/Facial Plastic Surgery Physician
License Number020891
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: