1013002930 NPI number — MR. HOWARD JOHN MIZE RPH

Table of content: MR. HOWARD JOHN MIZE RPH (NPI 1013002930)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1013002930 NPI number — MR. HOWARD JOHN MIZE RPH

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MIZE
Provider First Name:
HOWARD
Provider Middle Name:
JOHN
Provider Name Prefix Text:
MR.
Provider Name Suffix Text:
Provider Credential Text:
RPH
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1013002930
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/08/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3745 SEQUIOA TRAIL
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
VERONA
Provider Business Mailing Address State Name:
WI
Provider Business Mailing Address Postal Code:
53593
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
608-798-1315
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
639 S MAIN ST
Provider Second Line Business Practice Location Address:
SUITE 101
Provider Business Practice Location Address City Name:
DE FOREST
Provider Business Practice Location Address State Name:
WI
Provider Business Practice Location Address Postal Code:
53532-1478
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
608-846-2712
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
10/04/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 183500000X , with the licence number:  8946-040 , registered in the state of WI ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 33266000 , issued by the state of ( WI ) . This identifiers is of the category "MEDICAID".




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