Provider Demographics
NPI:1275510240
Name:MIZIN, LAKSHMI D (MD)
Entity Type:Individual
Prefix:
First Name:LAKSHMI
Middle Name:D
Last Name:MIZIN
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 1:187 FALLBROOK ST
Mailing Address - Street 2:P O BOX 577
Mailing Address - City:CARBONDALE
Mailing Address - State:PA
Mailing Address - Zip Code:18407-1861
Mailing Address - Country:US
Mailing Address - Phone:570-282-5189
Mailing Address - Fax:570-282-5551
Practice Address - Street 1:187 FALLBROOK ST
Practice Address - Street 2:
Practice Address - City:CARBONDALE
Practice Address - State:PA
Practice Address - Zip Code:18407-1861
Practice Address - Country:US
Practice Address - Phone:570-282-5189
Practice Address - Fax:570-282-5551
Is Sole Proprietor?:Yes
Enumeration Date:2005-12-29
Last Update Date:2012-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD024661E207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA0010040040004Medicaid
PA0010040040004Medicaid
D71235Medicare UPIN