Provider Demographics
NPI:1609885813
Name:MIZE, SHANNON (MD)
Entity Type:Individual
Prefix:MR
First Name:SHANNON
Middle Name:
Last Name:MIZE
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 1:208 HUDSON STREET
Mailing Address - Street 2:
Mailing Address - City:CUMMING
Mailing Address - State:GA
Mailing Address - Zip Code:30040
Mailing Address - Country:US
Mailing Address - Phone:770-887-5835
Mailing Address - Fax:770-781-4373
Practice Address - Street 1:208 HUDSON ST
Practice Address - Street 2:
Practice Address - City:CUMMING
Practice Address - State:GA
Practice Address - Zip Code:30040-2432
Practice Address - Country:US
Practice Address - Phone:770-887-5835
Practice Address - Fax:770-781-4373
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-05
Last Update Date:2010-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA018866207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA00179803B1Medicaid
GA000179803BMedicaid
GAE01092Medicare UPIN
GA00179803B1Medicaid