Healthcare Provider Details

I. General information

NPI: 1306150149
Provider Name (Legal Business Name): MIZUTA MEDICAL GROUP, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/04/2010
Last Update Date: 08/04/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3655 LOMITA BLVD STE 115
TORRANCE CA
90505-1906
US

IV. Provider business mailing address

3655 LOMITA BLVD STE 115
TORRANCE CA
90505-1906
US

V. Phone/Fax

Practice location:
  • Phone: 310-791-9696
  • Fax: 310-791-9646
Mailing address:
  • Phone: 310-791-9696
  • Fax: 310-791-9646

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number20A5290
License Number StateCA

VIII. Authorized Official

Name: DR. AKIHIRO MIZUTA
Title or Position: PRESIDENT
Credential: D.O.
Phone: 310-791-9696