Healthcare Provider Details

I. General information

NPI: 1548595697
Provider Name (Legal Business Name): RICHARD JEFFREY MIZE M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/07/2009
Last Update Date: 10/07/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1200 MARSHALL ST
CRESCENT CITY CA
95531-2217
US

IV. Provider business mailing address

1200 MARSHALL ST
CRESCENT CITY CA
95531-2217
US

V. Phone/Fax

Practice location:
  • Phone: 707-465-1126
  • Fax: 707-465-0937
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberG44645
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: