Healthcare Provider Details

I. General information

NPI: 1568488310
Provider Name (Legal Business Name): BARRY ALLEN MIZOCK MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/14/2006
Last Update Date: 01/15/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

840 S WOOD ST ROOM 439
CHICAGO IL
60612-4325
US

IV. Provider business mailing address

840 S WOOD ST ROOM 439
CHICAGO IL
60612-4325
US

V. Phone/Fax

Practice location:
  • Phone: 312-505-2055
  • Fax: 312-413-8389
Mailing address:
  • Phone: 312-505-2055
  • Fax: 312-413-8389

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number036053327
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: