Provider Demographics
NPI:1003634049
Name:MIZYED, SAMUEL E
Entity type:Individual
Prefix:
First Name:SAMUEL
Middle Name:E
Last Name:MIZYED
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1479 MARLIN AVE
Mailing Address - Street 2:
Mailing Address - City:FOSTER CITY
Mailing Address - State:CA
Mailing Address - Zip Code:94404-1448
Mailing Address - Country:US
Mailing Address - Phone:650-346-5949
Mailing Address - Fax:
Practice Address - Street 1:1080 MARINA VILLAGE PKWY STE 100
Practice Address - Street 2:
Practice Address - City:ALAMEDA
Practice Address - State:CA
Practice Address - Zip Code:94501-1078
Practice Address - Country:US
Practice Address - Phone:510-337-7950
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-09-30
Last Update Date:2024-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes172V00000XOther Service ProvidersCommunity Health WorkerGroup - Single Specialty