Healthcare Provider Details

I. General information

NPI: 1770810970
Provider Name (Legal Business Name): WALTER MIZELL INCORPORATE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/09/2009
Last Update Date: 11/09/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

350 5TH AVE 59TH FLOOR
NEW YORK NY
10118-0110
US

IV. Provider business mailing address

350 5TH AVE 59TH FLOOR
NEW YORK NY
10118-0110
US

V. Phone/Fax

Practice location:
  • Phone: 646-245-3279
  • Fax:
Mailing address:
  • Phone: 646-245-3279
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171W00000X
TaxonomyContractor
License Number
License Number State

VIII. Authorized Official

Name: ROBERT MIZELL
Title or Position: PRESIDENT
Credential:
Phone: 646-245-3279