Healthcare Provider Details

I. General information

NPI: 1497064521
Provider Name (Legal Business Name): MUTSUMI JOHN KIOKA M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/07/2010
Last Update Date: 07/20/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1707 W CHARLESTON BLVD STE 230
LAS VEGAS NV
89102-2353
US

IV. Provider business mailing address

1701 W CHARLESTON BLVD SUITE 230
LAS VEGAS NV
89102-2325
US

V. Phone/Fax

Practice location:
  • Phone: 702-671-5060
  • Fax: 702-671-5198
Mailing address:
  • Phone: 213-359-8018
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberA113478
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code207RP1001X
TaxonomyPulmonary Disease Physician
License Number16443
License Number StateNV
# 3
Primary TaxonomyN
Taxonomy Code207RC0200X
TaxonomyCritical Care Medicine (Internal Medicine) Physician
License Number16443
License Number StateNV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: