Provider Demographics
NPI:1629710157
Name:MIZELLE, JACK (MD)
Entity Type:Individual
Prefix:
First Name:JACK
Middle Name:
Last Name:MIZELLE
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 1:34 MAPLE AVE
Mailing Address - Street 2:
Mailing Address - City:HASTINGS ON HUDSON
Mailing Address - State:NY
Mailing Address - Zip Code:10706-1438
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:5323 HARRY HINES BLVD DALLAS
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75390-0001
Practice Address - Country:US
Practice Address - Phone:914-815-4611
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-04-13
Last Update Date:2022-04-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program