Healthcare Provider Details

I. General information

NPI: 1407806920
Provider Name (Legal Business Name): RON DWAINE MIXON O.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/12/2006
Last Update Date: 03/29/2023
Certification Date: 07/19/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2151 W OAKLAWN RD
PLEASANTON TX
78064-4604
US

IV. Provider business mailing address

PO BOX 474
POTEET TX
78065-0474
US

V. Phone/Fax

Practice location:
  • Phone: 830-569-3334
  • Fax: 830-281-3926
Mailing address:
  • Phone: 830-569-3334
  • Fax: 830-281-3926

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code152WC0802X
TaxonomyCorneal and Contact Management Optometrist
License Number5812TG
License Number StateTX
# 2
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number5812TG
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: