Healthcare Provider Details

I. General information

NPI: 1467406645
Provider Name (Legal Business Name): MARILYN SUZANNE MIZE M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/20/2006
Last Update Date: 02/06/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

90 JACKSON PIKE
GALLIPOLIS OH
45631-1560
US

IV. Provider business mailing address

90 JACKSON PIKE
GALLIPOLIS OH
45631-1560
US

V. Phone/Fax

Practice location:
  • Phone: 740-446-5002
  • Fax: 740-446-5883
Mailing address:
  • Phone: 740-446-5002
  • Fax: 740-446-5883

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License Number35-047722
License Number StateOH
# 2
Primary TaxonomyN
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License Number13777
License Number StateWV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: