Provider Demographics
NPI:1851396964
Name:MIZELL JR, LOUIS LEE JR (MD)
Entity Type:Individual
Prefix:MR
First Name:LOUIS
Middle Name:LEE
Last Name:MIZELL JR
Suffix:JR
Gender:M
Credentials:MD
Other - Prefix:
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Mailing Address - Street 1:5770 SO 250 E
Mailing Address - Street 2:SUITE 330
Mailing Address - City:MURRAY
Mailing Address - State:UT
Mailing Address - Zip Code:84107
Mailing Address - Country:US
Mailing Address - Phone:801-314-4455
Mailing Address - Fax:801-314-4433
Practice Address - Street 1:74 E KIMBALLS LN STE 330
Practice Address - Street 2:
Practice Address - City:DRAPER
Practice Address - State:UT
Practice Address - Zip Code:84020-5006
Practice Address - Country:US
Practice Address - Phone:801-545-8363
Practice Address - Fax:801-545-8133
Is Sole Proprietor?:Yes
Enumeration Date:2005-06-15
Last Update Date:2019-03-21
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
UT168364-12052080P0206X
UT82-168364-1205174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
No2080P0206XAllopathic & Osteopathic PhysiciansPediatricsPediatric Gastroenterology
Provider Identifiers
StateIdentifier IDID TypeIssuer
UTH09916Medicare UPIN