Provider Demographics
NPI:1467406645
Name:MIZE, MARILYN SUZANNE (MD)
Entity Type:Individual
Prefix:
First Name:MARILYN
Middle Name:SUZANNE
Last Name:MIZE
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 1:90 JACKSON PIKE
Mailing Address - Street 2:
Mailing Address - City:GALLIPOLIS
Mailing Address - State:OH
Mailing Address - Zip Code:45631-1560
Mailing Address - Country:US
Mailing Address - Phone:740-446-5002
Mailing Address - Fax:740-446-5883
Practice Address - Street 1:90 JACKSON PIKE
Practice Address - Street 2:
Practice Address - City:GALLIPOLIS
Practice Address - State:OH
Practice Address - Zip Code:45631-1560
Practice Address - Country:US
Practice Address - Phone:740-446-5002
Practice Address - Fax:740-446-5883
Is Sole Proprietor?:No
Enumeration Date:2006-05-20
Last Update Date:2015-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35-047722207RC0000X
WV13777207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
000000006897OtherANTHEM BCBS
060018483OtherRR MEDICARE
OH310917085035OtherCARESOURCE MEDICAID
WV0083707000Medicaid
OH0489716OtherMOLINA MEDICAID
OH000000185191OtherUNISON MEDICAID
001714031OtherMOUNTAIN STATE BCBS
A80395Medicare UPIN
060018483OtherRR MEDICARE
OH0489716OtherMOLINA MEDICAID