Healthcare Provider Details

I. General information

NPI: 1558398388
Provider Name (Legal Business Name): ERIC MIZUNO M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/27/2006
Last Update Date: 03/07/2023
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2720 W DIVISION ST
CHICAGO IL
60622-2853
US

IV. Provider business mailing address

PO BOX 3603
OAK BROOK IL
60522-3603
US

V. Phone/Fax

Practice location:
  • Phone: 773-523-8600
  • Fax: 773-687-9545
Mailing address:
  • Phone: 773-523-8600
  • Fax: 773-687-9545

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number036-082731
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: