Healthcare Provider Details

I. General information

NPI: 1417958703
Provider Name (Legal Business Name): JOHN J MIZENKO D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 08/09/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4100 WARRENSVILLE CENTER RD SUITE 203
WARRENSVILLE HEIGHTS OH
44122-7024
US

IV. Provider business mailing address

4100 WARRENSVILLE CENTER RD SUITE 203
WARRENSVILLE HEIGHTS OH
44122-7024
US

V. Phone/Fax

Practice location:
  • Phone: 216-561-0801
  • Fax:
Mailing address:
  • Phone: 216-561-0801
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RG0100X
TaxonomyGastroenterology Physician
License Number34001263M
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: