Provider Demographics
NPI:1386706646
Name:MIZUTA, AKIHIRO (DO)
Entity type:Individual
Prefix:DR
First Name:AKIHIRO
Middle Name:
Last Name:MIZUTA
Suffix:
Gender:M
Credentials:DO
Other - Prefix:DR
Other - First Name:AKIHIRO
Other - Middle Name:
Other - Last Name:MIZUTA
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:DO
Mailing Address - Street 1:3655 LOMITA BLVD
Mailing Address - Street 2:115
Mailing Address - City:TORRANCE
Mailing Address - State:CA
Mailing Address - Zip Code:90505
Mailing Address - Country:US
Mailing Address - Phone:310-791-9696
Mailing Address - Fax:310-791-9646
Practice Address - Street 1:3655 LOMITA BLVD
Practice Address - Street 2:115
Practice Address - City:TORRANCE
Practice Address - State:CA
Practice Address - Zip Code:90505
Practice Address - Country:US
Practice Address - Phone:310-791-9696
Practice Address - Fax:310-791-9646
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-14
Last Update Date:2010-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA20A5290207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
E17536Medicare UPIN