Provider Demographics
NPI:1518182666
Name:MICHAEL R. MIZENKO, D.O., INC.
Entity Type:Organization
Organization Name:MICHAEL R. MIZENKO, D.O., INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:R
Authorized Official - Last Name:MIZENKO
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:614-421-7722
Mailing Address - Street 1:772 N HIGH ST
Mailing Address - Street 2:SUITE 201
Mailing Address - City:COLUMBUS
Mailing Address - State:OH
Mailing Address - Zip Code:43215-1456
Mailing Address - Country:US
Mailing Address - Phone:614-421-7722
Mailing Address - Fax:614-421-7723
Practice Address - Street 1:772 N HIGH ST
Practice Address - Street 2:SUITE 201
Practice Address - City:COLUMBUS
Practice Address - State:OH
Practice Address - Zip Code:43215-1456
Practice Address - Country:US
Practice Address - Phone:614-421-7722
Practice Address - Fax:614-421-7723
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-16
Last Update Date:2008-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH340041682084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH111357000OtherMAGELLAN
OHMI0776852Medicare ID - Type UnspecifiedMEDICARE