Provider Demographics
NPI:1720086622
Name:MIX, WILLIAM AVERY (MD)
Entity type:Individual
Prefix:
First Name:WILLIAM
Middle Name:AVERY
Last Name:MIX
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 79777
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21279-0777
Mailing Address - Country:US
Mailing Address - Phone:434-654-7794
Mailing Address - Fax:844-883-6065
Practice Address - Street 1:435 MERCHANT WALK SQ STE 400
Practice Address - Street 2:
Practice Address - City:CHARLOTTESVILLE
Practice Address - State:VA
Practice Address - Zip Code:22902-6516
Practice Address - Country:US
Practice Address - Phone:434-654-1800
Practice Address - Fax:844-883-6065
Is Sole Proprietor?:No
Enumeration Date:2005-07-13
Last Update Date:2019-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101260244207Q00000X
PAMD029851E207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
B82432Medicare UPIN
VAVVN095AMedicare PIN
VAP01785017Medicare PIN
PA010056801OtherRR MEDICARE
PA0009299750008Medicaid
NY00051084001OtherUNIVERA
PA440542OtherBLUE SHIELD
OH2225685OtherOH MEDICAL ASSISTANCE
NY00815123OtherNY MEDICAL ASSISTANCE
PAP001388OtherGATEWAY
B82432Medicare UPIN
PA010056801OtherRR MEDICARE