Healthcare Provider Details

I. General information

NPI: 1235104480
Provider Name (Legal Business Name): CHRISTINE R MIZE O.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/21/2006
Last Update Date: 02/12/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

706 WASHINGTON ST
RAVENSWOOD WV
26164-1772
US

IV. Provider business mailing address

706 WASHINGTON ST
RAVENSWOOD WV
26164-1772
US

V. Phone/Fax

Practice location:
  • Phone: 304-273-2020
  • Fax:
Mailing address:
  • Phone: 304-273-2020
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number931-OD
License Number StateWV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: