Provider Demographics
NPI:1528041639
Name:MUTZIGER, JOHN C I (DO)
Entity Type:Individual
Prefix:DR
First Name:JOHN
Middle Name:C
Last Name:MUTZIGER
Suffix:I
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 2106
Mailing Address - Street 2:
Mailing Address - City:MERIDIAN
Mailing Address - State:MS
Mailing Address - Zip Code:39302-2106
Mailing Address - Country:US
Mailing Address - Phone:601-703-4282
Mailing Address - Fax:601-703-9283
Practice Address - Street 1:14884 HWY 15
Practice Address - Street 2:
Practice Address - City:DECATUR
Practice Address - State:MS
Practice Address - Zip Code:39327
Practice Address - Country:US
Practice Address - Phone:601-635-2258
Practice Address - Fax:601-635-2259
Is Sole Proprietor?:No
Enumeration Date:2005-11-22
Last Update Date:2016-10-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS10066207Q00000X, 207QA0401X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No207QA0401XAllopathic & Osteopathic PhysiciansFamily MedicineAddiction Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00011490Medicaid
MS080003169Medicare PIN
MS00011490Medicaid