Healthcare Provider Details

I. General information

NPI: 1538188594
Provider Name (Legal Business Name): GENE MIZUMOTO M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/19/2006
Last Update Date: 07/21/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 HOAG DR
NEWPORT BEACH CA
92663-4162
US

IV. Provider business mailing address

PO BOX 3589
NEWPORT BEACH CA
92659-8589
US

V. Phone/Fax

Practice location:
  • Phone: 949-610-7245
  • Fax: 657-241-7720
Mailing address:
  • Phone: 657-241-3600
  • Fax: 657-241-7708

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberG69566
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code208M00000X
TaxonomyHospitalist Physician
License NumberG69566
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: