Provider Demographics
NPI:1780737072
Name:MIZELLE, ERIC QUENTIN (MD)
Entity type:Individual
Prefix:
First Name:ERIC
Middle Name:QUENTIN
Last Name:MIZELLE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:3737 GLENWOOD AVE
Mailing Address - Street 2:SUITE 100
Mailing Address - City:RALEIGH
Mailing Address - State:NC
Mailing Address - Zip Code:27612-5515
Mailing Address - Country:US
Mailing Address - Phone:919-561-7999
Mailing Address - Fax:919-400-4395
Practice Address - Street 1:3737 GLENWOOD AVE
Practice Address - Street 2:SUITE 100
Practice Address - City:RALEIGH
Practice Address - State:NC
Practice Address - Zip Code:27612-5515
Practice Address - Country:US
Practice Address - Phone:919-561-7999
Practice Address - Fax:919-400-4395
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-19
Last Update Date:2013-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC2008-019712084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry