Provider Demographics
NPI:1306150149
Name:MIZUTA MEDICAL GROUP, INC.
Entity type:Organization
Organization Name:MIZUTA MEDICAL GROUP, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:AKIHIRO
Authorized Official - Middle Name:
Authorized Official - Last Name:MIZUTA
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:310-791-9696
Mailing Address - Street 1:3655 LOMITA BLVD STE 115
Mailing Address - Street 2:
Mailing Address - City:TORRANCE
Mailing Address - State:CA
Mailing Address - Zip Code:90505-1906
Mailing Address - Country:US
Mailing Address - Phone:310-791-9696
Mailing Address - Fax:310-791-9646
Practice Address - Street 1:3655 LOMITA BLVD STE 115
Practice Address - Street 2:
Practice Address - City:TORRANCE
Practice Address - State:CA
Practice Address - Zip Code:90505-1906
Practice Address - Country:US
Practice Address - Phone:310-791-9696
Practice Address - Fax:310-791-9646
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-08-04
Last Update Date:2010-08-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA20A5290207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty