Provider Demographics
NPI:1235104068
Name:MIZE, JESSE BEN III (OD)
Entity Type:Individual
Prefix:
First Name:JESSE
Middle Name:BEN
Last Name:MIZE
Suffix:III
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:706 WASHINGTON ST
Mailing Address - Street 2:
Mailing Address - City:RAVENSWOOD
Mailing Address - State:WV
Mailing Address - Zip Code:26164-1772
Mailing Address - Country:US
Mailing Address - Phone:304-273-2020
Mailing Address - Fax:
Practice Address - Street 1:706 WASHINGTON ST
Practice Address - Street 2:
Practice Address - City:RAVENSWOOD
Practice Address - State:WV
Practice Address - Zip Code:26164-1772
Practice Address - Country:US
Practice Address - Phone:304-273-2020
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-02-23
Last Update Date:2010-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV924-OD152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV0149760000Medicaid
WVDO1772Medicare PIN
WVU45502Medicare UPIN
WV0149760000Medicaid