Provider Demographics
NPI:1154375996
Name:MIXTER, ROGER C (MD)
Entity type:Individual
Prefix:DR
First Name:ROGER
Middle Name:C
Last Name:MIXTER
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Mailing Address - Street 1:5201 N PORT WASHINGTON RD
Mailing Address - Street 2:
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53217-4902
Mailing Address - Country:US
Mailing Address - Phone:414-963-0500
Mailing Address - Fax:414-963-0359
Practice Address - Street 1:5201 N PORT WASHINGTON RD
Practice Address - Street 2:
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53217-4902
Practice Address - Country:US
Practice Address - Phone:414-963-0500
Practice Address - Fax:414-963-0359
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
WI26326208200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208200000XAllopathic & Osteopathic PhysiciansPlastic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI30618600Medicaid
WI30618600Medicaid
000002705Medicare ID - Type Unspecified