Provider Demographics
NPI:1790953107
Name:BRENT L. MIXON, OD, LLC
Entity type:Organization
Organization Name:BRENT L. MIXON, OD, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:BRENT
Authorized Official - Middle Name:LEE
Authorized Official - Last Name:MIXON
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:979-849-7321
Mailing Address - Street 1:1713 E MULBERRY ST
Mailing Address - Street 2:
Mailing Address - City:ANGLETON
Mailing Address - State:TX
Mailing Address - Zip Code:77515-3916
Mailing Address - Country:US
Mailing Address - Phone:979-849-7321
Mailing Address - Fax:979-849-7321
Practice Address - Street 1:1713 E MULBERRY ST
Practice Address - Street 2:
Practice Address - City:ANGLETON
Practice Address - State:TX
Practice Address - Zip Code:77515-3916
Practice Address - Country:US
Practice Address - Phone:979-849-7321
Practice Address - Fax:979-849-7321
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-02-19
Last Update Date:2008-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX6944TG152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty