Provider Demographics
NPI:1306896634
Name:MIZERA, ANGELIQUE (DO)
Entity type:Individual
Prefix:DR
First Name:ANGELIQUE
Middle Name:
Last Name:MIZERA
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5145 N CALIFORNIA AVE
Mailing Address - Street 2:SCH PAIN CLINIC
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60625-3661
Mailing Address - Country:US
Mailing Address - Phone:773-989-1696
Mailing Address - Fax:773-561-0937
Practice Address - Street 1:5145 N CALIFORNIA AVE
Practice Address - Street 2:SCH PAIN CLINIC
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60625-3661
Practice Address - Country:US
Practice Address - Phone:773-989-1696
Practice Address - Fax:773-561-0937
Is Sole Proprietor?:No
Enumeration Date:2006-05-10
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036-083147208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILF83113Medicare UPIN