Provider Demographics
NPI:1083602270
Name:MOCHIZUKI, RONALD (MD)
Entity Type:Individual
Prefix:
First Name:RONALD
Middle Name:
Last Name:MOCHIZUKI
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:PO BOX 388320
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60638-8320
Mailing Address - Country:US
Mailing Address - Phone:773-767-8283
Mailing Address - Fax:773-767-8320
Practice Address - Street 1:12251 S 80TH AVE
Practice Address - Street 2:
Practice Address - City:PALOS HEIGHTS
Practice Address - State:IL
Practice Address - Zip Code:60463-1256
Practice Address - Country:US
Practice Address - Phone:708-923-5055
Practice Address - Fax:708-923-5058
Is Sole Proprietor?:Yes
Enumeration Date:2005-10-11
Last Update Date:2009-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036078225207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036078225Medicaid
IL01620954OtherBLUE SHIELD
250008036OtherRAILROAD MEDICARE
IL01620954OtherBLUE SHIELD
E18465Medicare UPIN