Healthcare Provider Details

I. General information

NPI: 1164412250
Provider Name (Legal Business Name): SHIZUO MUKAI M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/28/2005
Last Update Date: 10/25/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

243 CHARLES ST
BOSTON MA
02114-3002
US

IV. Provider business mailing address

243 CHARLES ST
BOSTON MA
02114-3002
US

V. Phone/Fax

Practice location:
  • Phone: 617-573-5050
  • Fax:
Mailing address:
  • Phone: 617-573-5050
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207W00000X
TaxonomyOphthalmology Physician
License Number51294
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: