Provider Demographics
NPI:1063536712
Name:MIZENKO, MICHAEL R (DO)
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:R
Last Name:MIZENKO
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:777 BANNOCK ST
Mailing Address - Street 2:
Mailing Address - City:DENVER
Mailing Address - State:CO
Mailing Address - Zip Code:80204-4507
Mailing Address - Country:US
Mailing Address - Phone:614-738-6442
Mailing Address - Fax:
Practice Address - Street 1:777 BANNOCK ST
Practice Address - Street 2:
Practice Address - City:DENVER
Practice Address - State:CO
Practice Address - Zip Code:80204-4507
Practice Address - Country:US
Practice Address - Phone:614-738-6442
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-19
Last Update Date:2021-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH34-0041682084P0800X
CODR.00543172084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0635487Medicaid
OH111357000OtherMAGELLAN
OHMI0776852Medicare ID - Type UnspecifiedMEDICARE
OHMI0776854Medicare PIN
OH111357000OtherMAGELLAN