Provider Demographics
NPI:1881688893
Name:MIZELLE, KATHERINE MONTAGUE (MD)
Entity Type:Individual
Prefix:
First Name:KATHERINE
Middle Name:MONTAGUE
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 1:700 CHILDREN'S DRIVE
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:OH
Mailing Address - Zip Code:43205-2664
Mailing Address - Country:US
Mailing Address - Phone:614-722-3100
Mailing Address - Fax:614-722-2549
Practice Address - Street 1:700 CHILDREN'S DRIVE
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:OH
Practice Address - Zip Code:43205-2664
Practice Address - Country:US
Practice Address - Phone:614-722-3100
Practice Address - Fax:614-722-2549
Is Sole Proprietor?:No
Enumeration Date:2005-09-06
Last Update Date:2016-01-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH350785292080P0202X, 2080P0203X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080P0202XAllopathic & Osteopathic PhysiciansPediatricsPediatric Cardiology
No2080P0203XAllopathic & Osteopathic PhysiciansPediatricsPediatric Critical Care Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV1802977000Medicaid
KY64027246Medicaid
OHMI4040601OtherMEDICARE
OHMI4040602OtherMEDICARE
OH2211403Medicaid
KY64027246Medicaid