Provider Demographics
NPI:1457490955
Name:MIZELLE, KRISTI VERGENA (MD)
Entity Type:Individual
Prefix:
First Name:KRISTI
Middle Name:VERGENA
Last Name:MIZELLE
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:860 OMNI BLVD
Mailing Address - Street 2:SUITE 303
Mailing Address - City:NEWPORT NEWS
Mailing Address - State:VA
Mailing Address - Zip Code:23606-4430
Mailing Address - Country:US
Mailing Address - Phone:757-232-8769
Mailing Address - Fax:757-232-8875
Practice Address - Street 1:704 THIMBLE SHOALS BLVD
Practice Address - Street 2:BLDG. 300 A
Practice Address - City:NEWPORT NEWS
Practice Address - State:VA
Practice Address - Zip Code:23606-4544
Practice Address - Country:US
Practice Address - Phone:757-595-4300
Practice Address - Fax:757-591-9297
Is Sole Proprietor?:No
Enumeration Date:2007-02-05
Last Update Date:2013-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD73504207RR0500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RR0500XAllopathic & Osteopathic PhysiciansInternal MedicineRheumatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD051642200Medicaid
MD236061ZBLSMedicare PIN