Healthcare Provider Details

I. General information

NPI: 1558654418
Provider Name (Legal Business Name): MARISA CARLY MIZUS MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/25/2011
Last Update Date: 06/03/2025
Certification Date: 06/03/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10753 FALLS RD STE 225
LUTHERVILLE MD
21093-4597
US

IV. Provider business mailing address

10753 FALLS RD STE 225
LUTHERVILLE MD
21093-4597
US

V. Phone/Fax

Practice location:
  • Phone: 410-583-2604
  • Fax: 410-583-2841
Mailing address:
  • Phone: 410-583-2828
  • Fax: 410-601-4833

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberMD449982
License Number StatePA
# 2
Primary TaxonomyN
Taxonomy Code208M00000X
TaxonomyHospitalist Physician
License NumberD83503
License Number StateMD
# 3
Primary TaxonomyY
Taxonomy Code207RR0500X
TaxonomyRheumatology Physician
License NumberD83503
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: