Healthcare Provider Details

I. General information

NPI: 1861418808
Provider Name (Legal Business Name): MICHAEL BRUCE MIZOGUCHI M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/14/2006
Last Update Date: 08/03/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2434 HARRISON AVE
EUREKA CA
95501-3219
US

IV. Provider business mailing address

2434 HARRISON AVE
EUREKA CA
95501-3219
US

V. Phone/Fax

Practice location:
  • Phone: 707-443-5685
  • Fax: 707-443-9880
Mailing address:
  • Phone: 707-443-5685
  • Fax: 707-443-9880

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207W00000X
TaxonomyOphthalmology Physician
License NumberA70161
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: