Provider Demographics
NPI:1942285218
Name:PORUBOVICH-MIZENKO, JEANETTE (MD)
Entity Type:Individual
Prefix:
First Name:JEANETTE
Middle Name:
Last Name:PORUBOVICH-MIZENKO
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:PO BOX 30076
Mailing Address - Street 2:
Mailing Address - City:CLEVELAND
Mailing Address - State:OH
Mailing Address - Zip Code:44130-0076
Mailing Address - Country:US
Mailing Address - Phone:440-816-5379
Mailing Address - Fax:
Practice Address - Street 1:55 W WATERLOO RD
Practice Address - Street 2:
Practice Address - City:AKRON
Practice Address - State:OH
Practice Address - Zip Code:44319-1116
Practice Address - Country:US
Practice Address - Phone:330-724-7715
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-12-09
Last Update Date:2012-09-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35-05-5955-P207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2238206Medicaid
OHCN3937OtherRAILROAD MEDICARE GROUP
OH2228330OtherAETNA
OH000000028998OtherANTHEM
OH0935420Medicaid
OH80207OtherQUAL CHOICE
OHPO0720192Medicare PIN
OH0935420Medicaid
OHCN3937OtherRAILROAD MEDICARE GROUP