Provider Demographics
NPI:1629710157
Name:MIZELLE, JACK (MD)
Entity type:Individual
Prefix:
First Name:JACK
Middle Name:
Last Name:MIZELLE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1000 4TH ST SW
Mailing Address - Street 2:
Mailing Address - City:MASON CITY
Mailing Address - State:IA
Mailing Address - Zip Code:50401-2800
Mailing Address - Country:US
Mailing Address - Phone:641-428-7000
Mailing Address - Fax:
Practice Address - Street 1:1010 4TH ST SW STE 240
Practice Address - Street 2:
Practice Address - City:MASON CITY
Practice Address - State:IA
Practice Address - Zip Code:50401-2856
Practice Address - Country:US
Practice Address - Phone:641-428-7766
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-04-13
Last Update Date:2025-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC93144208D00000X
IA54186207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice