Healthcare Provider Details

I. General information

NPI: 1417947292
Provider Name (Legal Business Name): RICHARD ERIC MIZNER MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/24/2005
Last Update Date: 07/31/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

55 FRUIT ST PEDIATRIC GROUP PRACTICE YAW 6
BOSTON MA
02114-2621
US

IV. Provider business mailing address

PO BOX 9142 MASS GENERAL PHYSICIAN ORGANIZATION
CHARLESTOWN MA
02129-9142
US

V. Phone/Fax

Practice location:
  • Phone: 617-726-2728
  • Fax: 617-724-3948
Mailing address:
  • Phone: 617-726-2728
  • Fax: 617-724-3948

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number81000
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: