Provider Demographics
NPI:1053490342
Name:MIXSON, CHARLES M (MD)
Entity type:Individual
Prefix:DR
First Name:CHARLES
Middle Name:M
Last Name:MIXSON
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 1:150 NACOOCHEE AVE
Mailing Address - Street 2:
Mailing Address - City:ATHENS
Mailing Address - State:GA
Mailing Address - Zip Code:30601-1823
Mailing Address - Country:US
Mailing Address - Phone:706-546-7908
Mailing Address - Fax:706-546-1944
Practice Address - Street 1:150 NACOOCHEE AVE
Practice Address - Street 2:
Practice Address - City:ATHENS
Practice Address - State:GA
Practice Address - Zip Code:30601-1823
Practice Address - Country:US
Practice Address - Phone:706-546-7908
Practice Address - Fax:706-546-1944
Is Sole Proprietor?:No
Enumeration Date:2006-11-06
Last Update Date:2012-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA052997207YS0012X, 207YS0123X, 207YX0007X, 207YX0905X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207YS0012XAllopathic & Osteopathic PhysiciansOtolaryngologySleep Medicine
No207YS0123XAllopathic & Osteopathic PhysiciansOtolaryngologyFacial Plastic Surgery
No207YX0007XAllopathic & Osteopathic PhysiciansOtolaryngologyPlastic Surgery within the Head & Neck
No207YX0905XAllopathic & Osteopathic PhysiciansOtolaryngologyOtolaryngology/Facial Plastic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA052997OtherGA. STATE LICENSE