Provider Demographics
NPI:1417937376
Name:MIZUGUCHI, NANA N (MD)
Entity Type:Individual
Prefix:
First Name:NANA
Middle Name:N
Last Name:MIZUGUCHI
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 1:2341 LIME KILN LANE
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40222
Mailing Address - Country:US
Mailing Address - Phone:502-899-9979
Mailing Address - Fax:502-899-9939
Practice Address - Street 1:2341 LIME KILN LANE
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40222
Practice Address - Country:US
Practice Address - Phone:502-899-9979
Practice Address - Fax:502-899-9939
Is Sole Proprietor?:No
Enumeration Date:2006-01-18
Last Update Date:2014-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY33262208200000X, 208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208200000XAllopathic & Osteopathic PhysiciansPlastic Surgery
No208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200439580OtherINDIANA MEDICAID
IN200439580Medicaid
KY64064777Medicaid
KY0687823Medicare ID - Type Unspecified
IN200439580OtherINDIANA MEDICAID