Healthcare Provider Details

I. General information

NPI: 1699774919
Provider Name (Legal Business Name): WESLEY T MIZUTANI MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/19/2005
Last Update Date: 11/05/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2925 N PALO VERDE
LONG BEACH CA
90815
US

IV. Provider business mailing address

2925 N PALO VERDE
LONG BEACH CA
90815
US

V. Phone/Fax

Practice location:
  • Phone: 714-964-6229
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RR0500X
TaxonomyRheumatology Physician
License NumberA40745
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: