Healthcare Provider Details

I. General information

NPI: 1902896525
Provider Name (Legal Business Name): YOSHINOBU MIFUNE MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/25/2005
Last Update Date: 11/20/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

28078 BAXTER RD SUITE 410
MURRIETA CA
92563-1402
US

IV. Provider business mailing address

28078 BAXTER RD SUITE 410
MURRIETA CA
92563-1402
US

V. Phone/Fax

Practice location:
  • Phone: 951-566-9800
  • Fax: 951-566-9801
Mailing address:
  • Phone: 951-290-4061
  • Fax: 951-290-4062

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberC54792
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code2083P0011X
TaxonomyUndersea and Hyperbaric Medicine (Preventive Medicine) Physician
License NumberC54792
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: