Healthcare Provider Details

I. General information

NPI: 1114280765
Provider Name (Legal Business Name): KATHRYN MIZERA M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/19/2012
Last Update Date: 05/04/2023
Certification Date: 05/04/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

34800 BOB WILSON DR
SAN DIEGO CA
92134-1098
US

IV. Provider business mailing address

1431 PACIFIC HWY UNIT 104
SAN DIEGO CA
92101-8300
US

V. Phone/Fax

Practice location:
  • Phone: 773-501-9673
  • Fax:
Mailing address:
  • Phone: 773-501-9673
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number23708
License Number StateMS
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number23241
License Number StateNV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: