MEDICARE: ERIC MIZUNO M.D.

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	207R00000X	Internal Medicine Physician	036-082731	IL

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
3	F400186347	OTHER	IL	MEDICARE

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	10640555	OTHER	IL	CAQH
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
4	QXIPQ0000100695	OTHER	IL	AETNA BETTER HEALTH

General Provider Information

NPI Number	:	1558398388
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	ERIC MIZUNO M.D.

Provider Business Mailing Address
First Line	:	PO BOX 3603
Second Line	:
City	:	OAK BROOK
State	:	IL
Zip	:	60522-3603
Country	:	US
Telephone Number	:	773-523-8600
Fax Number	:	773-687-9545

Provider Business Practice Location Address
First Line	:	2720 W DIVISION ST
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60622-2853
Country	:	US
Telephone Number	:	773-523-8600
Fax Number	:	773-687-9545

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

Provider Enumeration Date	:	06/27/2006
Last Update Date	:	03/07/2023

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