Healthcare Provider Details

I. General information

NPI: 1013990449
Provider Name (Legal Business Name): RICHARD MIZUGUCHI MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/21/2005
Last Update Date: 12/06/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10 UNION SQ E SUITE 3C
NEW YORK NY
10003-3314
US

IV. Provider business mailing address

PO BOX 95000-2442
PHILADELPHIA PA
19195-2442
US

V. Phone/Fax

Practice location:
  • Phone: 212-523-5898
  • Fax:
Mailing address:
  • Phone: 212-844-8800
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License Number224462
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: