Provider Demographics
NPI:1558398388
Name:MIZUNO, ERIC (MD)
Entity Type:Individual
Prefix:
First Name:ERIC
Middle Name:
Last Name:MIZUNO
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 3603
Mailing Address - Street 2:
Mailing Address - City:OAK BROOK
Mailing Address - State:IL
Mailing Address - Zip Code:60522-3603
Mailing Address - Country:US
Mailing Address - Phone:773-523-8600
Mailing Address - Fax:773-687-9545
Practice Address - Street 1:2720 W DIVISION ST
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60622-2853
Practice Address - Country:US
Practice Address - Phone:773-523-8600
Practice Address - Fax:773-687-9545
Is Sole Proprietor?:No
Enumeration Date:2006-06-27
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036-082731207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL10640555OtherCAQH
IL036-082731Medicaid
ILF400186347OtherMEDICARE
ILQXIPQ0000100695OtherAETNA BETTER HEALTH
ILQXIPQ0000100695OtherAETNA BETTER HEALTH
ILQXIPQ0000100695OtherAETNA BETTER HEALTH
ILL91270Medicare ID - Type Unspecified