Provider Demographics
NPI:1154410173
Name:MIZELL, MYRON W (MD)
Entity type:Individual
Prefix:DR
First Name:MYRON
Middle Name:W
Last Name:MIZELL
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 2580
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:MO
Mailing Address - Zip Code:65801-2580
Mailing Address - Country:US
Mailing Address - Phone:417-829-4620
Mailing Address - Fax:
Practice Address - Street 1:2115 S FREMONT AVE
Practice Address - Street 2:SUITE 4300
Practice Address - City:SPRINGFIELD
Practice Address - State:MO
Practice Address - Zip Code:65804-2239
Practice Address - Country:US
Practice Address - Phone:417-820-3911
Practice Address - Fax:417-820-3924
Is Sole Proprietor?:No
Enumeration Date:2006-10-11
Last Update Date:2013-05-16
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MOR5326207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO200946556Medicaid
MOA13577Medicare UPIN
MO200946556Medicaid
MO479013268Medicare PIN