Healthcare Provider Details

I. General information

NPI: 1629710157
Provider Name (Legal Business Name): JACK MIZELLE MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/13/2022
Last Update Date: 07/15/2025
Certification Date: 07/15/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1010 4TH ST SW STE 240
MASON CITY IA
50401-2856
US

IV. Provider business mailing address

1000 4TH ST SW
MASON CITY IA
50401-2800
US

V. Phone/Fax

Practice location:
  • Phone: 641-428-7766
  • Fax:
Mailing address:
  • Phone: 641-428-7000
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number54186
License Number StateIA
# 2
Primary TaxonomyN
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number93144
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: