Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 207YS0123X | Facial Plastic Surgeon | 052997 | GA |
N | 207YX0007X | Plastic Surgeon (Head & Neck) | 052997 | GA |
N | 207YX0905X | Otolaryngology/Facial Plastic Surgery | 052997 | GA |
NPI | 1053490342 |
---|---|
Provider Name | Dr. Charles M. Mixson |
First Address | Athens, GA 30601-1823 |
Second Address | Athens, GA 30601-1823 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 06/11/2006 |
Last Update Date | 24/10/2012 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
052997 | GA. STATE LICENSE (01) | GA |