MEDICARE: DEREK I MITO MD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207Q00000X	Family Medicine Physician	9932	NV
2	207Q00000X	Family Medicine Physician	MD-20577	HI

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
3	80173665	OTHER	NV	RAILROAD MEDICARE

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	11041229	OTHER		CAQH

General Provider Information

NPI Number	:	1558335042
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DEREK I MITO MD

Provider Business Mailing Address
First Line	:	599 FARRINGTON HWY STE 201
Second Line	:
City	:	KAPOLEI
State	:	HI
Zip	:	96707-2028
Country	:	US
Telephone Number	:	808-674-9500
Fax Number	:

Provider Business Practice Location Address
First Line	:	599 FARRINGTON HWY STE 201
Second Line	:
City	:	KAPOLEI
State	:	HI
Zip	:	96707-2028
Country	:	US
Telephone Number	:	808-674-9500
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	02/14/2006
Last Update Date	:	08/04/2020

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Directions to “ DEREK I MITO MD” Practice Location

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