Provider Demographics
NPI:1760427678
Name:MIZELLE, DONNA GRIMSLEY (MD)
Entity Type:Individual
Prefix:DR
First Name:DONNA
Middle Name:GRIMSLEY
Last Name:MIZELLE
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:25 EAST CLARK STREET
Mailing Address - Street 2:
Mailing Address - City:PINEWOOD
Mailing Address - State:SC
Mailing Address - Zip Code:29125
Mailing Address - Country:US
Mailing Address - Phone:803-774-4500
Mailing Address - Fax:803-452-5712
Practice Address - Street 1:25 EAST CLARK STREET
Practice Address - Street 2:
Practice Address - City:PINEWOOD
Practice Address - State:SC
Practice Address - Zip Code:29125
Practice Address - Country:US
Practice Address - Phone:803-774-4500
Practice Address - Fax:803-452-5712
Is Sole Proprietor?:No
Enumeration Date:2006-06-17
Last Update Date:2022-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC200300669207Q00000X
SC22449207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC89135JNMedicaid
SCL36646Medicaid
NC2019811Medicare ID - Type Unspecified