Healthcare Provider Details

I. General information

NPI: 1780737072
Provider Name (Legal Business Name): ERIC QUENTIN MIZELLE MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/19/2007
Last Update Date: 09/10/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3737 GLENWOOD AVE SUITE 100
RALEIGH NC
27612-5515
US

IV. Provider business mailing address

3737 GLENWOOD AVE SUITE 100
RALEIGH NC
27612-5515
US

V. Phone/Fax

Practice location:
  • Phone: 919-561-7999
  • Fax: 919-400-4395
Mailing address:
  • Phone: 919-561-7999
  • Fax: 919-400-4395

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number2008-01971
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: