Provider Demographics
NPI:1225271810
Name:MIZELL, WILLIAM LEONARD (DO)
Entity Type:Individual
Prefix:DR
First Name:WILLIAM
Middle Name:LEONARD
Last Name:MIZELL
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 578
Mailing Address - Street 2:
Mailing Address - City:FAIRACRES
Mailing Address - State:NM
Mailing Address - Zip Code:88033-0578
Mailing Address - Country:US
Mailing Address - Phone:505-383-3543
Mailing Address - Fax:
Practice Address - Street 1:1525 MORRIS RD SE
Practice Address - Street 2:
Practice Address - City:LOS LUNAS
Practice Address - State:NM
Practice Address - Zip Code:87031-7332
Practice Address - Country:US
Practice Address - Phone:505-383-3543
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-04-12
Last Update Date:2009-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMA-110498207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MSF96282Medicare UPIN