Healthcare Provider Details

I. General information

NPI: 1275510240
Provider Name (Legal Business Name): LAKSHMI D MIZIN MD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/29/2005
Last Update Date: 04/25/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

187 FALLBROOK ST
CARBONDALE PA
18407-1861
US

IV. Provider business mailing address

187 FALLBROOK ST P O BOX 577
CARBONDALE PA
18407-1861
US

V. Phone/Fax

Practice location:
  • Phone: 570-282-5189
  • Fax: 570-282-5551
Mailing address:
  • Phone: 570-282-5189
  • Fax: 570-282-5551

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License NumberMD024661E
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: