Healthcare Provider Details

I. General information

NPI: 1063536712
Provider Name (Legal Business Name): MICHAEL R. MIZENKO D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/19/2007
Last Update Date: 03/11/2021
Certification Date: 03/11/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

777 BANNOCK ST
DENVER CO
80204-4507
US

IV. Provider business mailing address

777 BANNOCK ST
DENVER CO
80204-4507
US

V. Phone/Fax

Practice location:
  • Phone: 614-738-6442
  • Fax:
Mailing address:
  • Phone: 614-738-6442
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number34-004168
License Number StateOH
# 2
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License NumberDR.0054317
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: