Healthcare Provider Details

I. General information

NPI: 1730386145
Provider Name (Legal Business Name): COURTNEY TAMIKO MIZUHARA-CHENG DO
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/29/2007
Last Update Date: 06/15/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2901 OCEAN PARK BLVD STE 207
SANTA MONICA CA
90405-2964
US

IV. Provider business mailing address

2901 OCEAN PARK BLVD STE 207
SANTA MONICA CA
90405-2964
US

V. Phone/Fax

Practice location:
  • Phone: 424-272-6513
  • Fax:
Mailing address:
  • Phone: 424-272-6513
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number20A10710
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: