1396895900 NPI number — MAVIS A MIZUMOTO PH.D.

Table of content: MAVIS A MIZUMOTO PH.D. (NPI 1396895900)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1396895900 NPI number — MAVIS A MIZUMOTO PH.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MIZUMOTO
Provider First Name:
MAVIS
Provider Middle Name:
A
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
PH.D.
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1396895900
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
01/30/2017
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2603 PETER ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
HONOLULU
Provider Business Mailing Address State Name:
HI
Provider Business Mailing Address Postal Code:
96816-2013
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
808-735-2378
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1268 YOUNG ST
Provider Second Line Business Practice Location Address:
STE 200
Provider Business Practice Location Address City Name:
HONOLULU
Provider Business Practice Location Address State Name:
HI
Provider Business Practice Location Address Postal Code:
96814-1801
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
808-735-2378
Provider Business Practice Location Address Fax Number:
808-597-8183
Provider Enumeration Date:
01/12/2007

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 103TC0700X , with the licence number:  PSY-481 , registered in the state of HI ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 040501-01 , issued by the state of ( HI ) . This identifiers is of the category "MEDICAID".
  • Identifier: PSY481-01 . This is a "MDX" identifier , issued by the state of ( HI ) . This identifiers is of the category "OTHER".
  • Identifier: PSY481-01 . This is a "DESERT MUTUAL" identifier , issued by the state of ( HI ) . This identifiers is of the category "OTHER".
  • Identifier: 192907 . This is a "HMN" identifier , issued by the state of ( HI ) . This identifiers is of the category "OTHER".
  • Identifier: PSY481-01 . This is a "CIGNA" identifier , issued by the state of ( HI ) . This identifiers is of the category "OTHER".
  • Identifier: 192907 . This is a "HMA" identifier , issued by the state of ( HI ) . This identifiers is of the category "OTHER".
  • Identifier: C044590-8 . This is a "HMSA" identifier , issued by the state of ( HI ) . This identifiers is of the category "OTHER".
  • Identifier: 0007919184 . This is a "AETNA" identifier , issued by the state of ( HI ) . This identifiers is of the category "OTHER".
  • Identifier: 192907 . This is a "SUMMERLIN" identifier , issued by the state of ( HI ) . This identifiers is of the category "OTHER".
  • Identifier: PSY481-01 . This is a "UHC" identifier , issued by the state of ( HI ) . This identifiers is of the category "OTHER".




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