Provider Demographics
NPI:1427410679
Name:MIZUO, COLIN MATTHEW (DPM)
Entity type:Individual
Prefix:DR
First Name:COLIN
Middle Name:MATTHEW
Last Name:MIZUO
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1550 NW NAITO PKWY APT 225
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97209-4179
Mailing Address - Country:US
Mailing Address - Phone:214-629-1409
Mailing Address - Fax:301-588-3419
Practice Address - Street 1:1827 NE 44TH AVE STE 100
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97213-1443
Practice Address - Country:US
Practice Address - Phone:503-284-2000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-03-27
Last Update Date:2024-11-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORDP221624213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatristGroup - Single Specialty