Basic Information
| Provider Information | |||||||||
| NPI: | 1760427678 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MIZELLE | ||||||||
| FirstName: | DONNA | ||||||||
| MiddleName: | GRIMSLEY | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
| OtherOrganizationName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 25 EAST CLARK STREET | ||||||||
| Address2: | |||||||||
| City: | PINEWOOD | ||||||||
| State: | SC | ||||||||
| PostalCode: | 29125 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8037744500 | ||||||||
| FaxNumber: | 8034525712 | ||||||||
| Practice Location | |||||||||
| Address1: | 25 EAST CLARK STREET | ||||||||
| Address2: | |||||||||
| City: | PINEWOOD | ||||||||
| State: | SC | ||||||||
| PostalCode: | 29125 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8037744500 | ||||||||
| FaxNumber: | 8034525712 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/17/2006 | ||||||||
| LastUpdateDate: | 10/25/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
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| NPICertificationDate: | 10/25/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 200300669 | NC | N | Allopathic & Osteopathic Physicians | Family Medicine | 207Q00000X | 22449 | SC | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 89135JN | 05 | NC | MEDICAID | L36646 | 05 | SC | MEDICAID |