Healthcare Provider Details

I. General information

NPI: 1720086622
Provider Name (Legal Business Name): WILLIAM AVERY MIX MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/13/2005
Last Update Date: 04/18/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

435 MERCHANT WALK SQ STE 400
CHARLOTTESVILLE VA
22902-6516
US

IV. Provider business mailing address

PO BOX 79777
BALTIMORE MD
21279-0777
US

V. Phone/Fax

Practice location:
  • Phone: 434-654-1800
  • Fax: 844-883-6065
Mailing address:
  • Phone: 434-654-7794
  • Fax: 844-883-6065

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number0101260244
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: