Provider Demographics
NPI:1679701791
Name:HIXSON, HARRY R JR (MD)
Entity type:Individual
Prefix:
First Name:HARRY
Middle Name:R
Last Name:HIXSON
Suffix:JR
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 1:2001 LAUREL AVE STE N304
Mailing Address - Street 2:
Mailing Address - City:KNOXVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37916-1810
Mailing Address - Country:US
Mailing Address - Phone:865-766-6870
Mailing Address - Fax:
Practice Address - Street 1:2001 LAUREL AVE # N304
Practice Address - Street 2:
Practice Address - City:KNOXVILLE
Practice Address - State:TN
Practice Address - Zip Code:37916-1810
Practice Address - Country:US
Practice Address - Phone:865-766-6870
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-06-26
Last Update Date:2021-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA01012505332085N0700X, 2085R0204X
VA0116021819390200000X
TN555562085R0204X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0204XAllopathic & Osteopathic PhysiciansRadiologyVascular & Interventional Radiology
No2085N0700XAllopathic & Osteopathic PhysiciansRadiologyNeuroradiology
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
TNQ028263Medicaid
TN103I303216OtherMEDICARE
VA1679701791Medicaid
VA1679701791Medicaid