Healthcare Provider Details

I. General information

NPI: 1770747305
Provider Name (Legal Business Name): MIZIN PARK KAWASAKI M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/13/2008
Last Update Date: 05/26/2022
Certification Date: 05/26/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

425 HAALAND DR SUITE 104
THOUSAND OAKS CA
91361-5229
US

IV. Provider business mailing address

24422 AVENIDA DE LA CARLOTA STE 300
LAGUNA HILLS CA
92653-3628
US

V. Phone/Fax

Practice location:
  • Phone: 805-494-1948
  • Fax: 805-494-1947
Mailing address:
  • Phone: 949-599-2434
  • Fax: 499-599-2430

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberG063471
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: