Provider Demographics
NPI:1003917287
Name:NISHIMOTO, MITCHELL (MD)
Entity Type:Individual
Prefix:DR
First Name:MITCHELL
Middle Name:
Last Name:NISHIMOTO
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15243 VANOWEN ST
Mailing Address - Street 2:STE 408
Mailing Address - City:VAN NUYS
Mailing Address - State:CA
Mailing Address - Zip Code:91405-3658
Mailing Address - Country:US
Mailing Address - Phone:818-785-3889
Mailing Address - Fax:818-780-2106
Practice Address - Street 1:15243 VANOWEN ST
Practice Address - Street 2:SUITE 406
Practice Address - City:VAN NUYS
Practice Address - State:CA
Practice Address - Zip Code:91405-3605
Practice Address - Country:US
Practice Address - Phone:818-785-3889
Practice Address - Fax:818-780-2106
Is Sole Proprietor?:No
Enumeration Date:2006-09-26
Last Update Date:2018-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG76976207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAWG76976CMedicare ID - Type UnspecifiedMEDICARE