Healthcare Provider Details

I. General information

NPI: 1447518964
Provider Name (Legal Business Name): MITSUHIKO TSUKIMOTO M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/03/2012
Last Update Date: 07/19/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

25845 BARTON RD
LOMA LINDA CA
92354-3899
US

IV. Provider business mailing address

54701 FILE NUMBER
LOS ANGELES CA
90074-4701
US

V. Phone/Fax

Practice location:
  • Phone: 909-558-2828
  • Fax:
Mailing address:
  • Phone: 909-651-4300
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberA129205
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: