Healthcare Provider Details

I. General information

NPI: 1639135049
Provider Name (Legal Business Name): SUSAN MIZZI R D
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/25/2006
Last Update Date: 09/19/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

445 LENOX RD
BROOKLYN NY
11203-2017
US

IV. Provider business mailing address

445 LENOX RD
BROOKLYN NY
11203-2017
US

V. Phone/Fax

Practice location:
  • Phone: 718-270-1485
  • Fax:
Mailing address:
  • Phone: 718-270-1485
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133N00000X
TaxonomyNutritionist
License Number0021171
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: