Healthcare Provider Details

I. General information

NPI: 1649624693
Provider Name (Legal Business Name): BRANDON MIZELL M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/15/2016
Last Update Date: 09/15/2020
Certification Date: 09/15/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1907 MISSION 66
VICKSBURG MS
39180-3711
US

IV. Provider business mailing address

1907 MISSION 66
VICKSBURG MS
39180-3711
US

V. Phone/Fax

Practice location:
  • Phone: 601-636-1173
  • Fax:
Mailing address:
  • Phone: 601-636-1173
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number26789
License Number StateMS
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number26789
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: