Provider Demographics
NPI:1568488310
Name:MIZOCK, BARRY ALLEN (MD)
Entity Type:Individual
Prefix:DR
First Name:BARRY
Middle Name:ALLEN
Last Name:MIZOCK
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:840 S WOOD ST
Mailing Address - Street 2:ROOM 439
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60612-4325
Mailing Address - Country:US
Mailing Address - Phone:312-505-2055
Mailing Address - Fax:312-413-8389
Practice Address - Street 1:840 S WOOD ST
Practice Address - Street 2:ROOM 439
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60612-4325
Practice Address - Country:US
Practice Address - Phone:312-505-2055
Practice Address - Fax:312-413-8389
Is Sole Proprietor?:No
Enumeration Date:2006-07-14
Last Update Date:2013-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036053327207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILI59131Medicare UPIN