Healthcare Provider Details

I. General information

NPI: 1295716090
Provider Name (Legal Business Name): MARK MITSUYUKI MORIWAKI M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/08/2005
Last Update Date: 07/29/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4150 V ST SUITE G400
SACRAMENTO CA
95817-1460
US

IV. Provider business mailing address

4150 V ST SUITE G400
SACRAMENTO CA
95817-1460
US

V. Phone/Fax

Practice location:
  • Phone: 916-734-3730
  • Fax: 916-734-7953
Mailing address:
  • Phone: 916-734-3730
  • Fax: 916-734-7953

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RE0101X
TaxonomyEndocrinology, Diabetes & Metabolism Physician
License NumberG74752
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: