Provider Demographics
NPI:1568563625
Name:MIMURA, NANA (MD)
Entity Type:Individual
Prefix:
First Name:NANA
Middle Name:
Last Name:MIMURA
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3030 N ROCKY POINT DR W
Mailing Address - Street 2:STE 670
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33607-5803
Mailing Address - Country:US
Mailing Address - Phone:813-289-6597
Mailing Address - Fax:813-289-6592
Practice Address - Street 1:3030 N ROCKY POINT DR W
Practice Address - Street 2:STE 670
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33607-5803
Practice Address - Country:US
Practice Address - Phone:239-597-0583
Practice Address - Fax:239-597-5628
Is Sole Proprietor?:No
Enumeration Date:2006-09-25
Last Update Date:2016-05-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301065734207R00000X
FLME111706207R00000X, 208M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No208M00000XAllopathic & Osteopathic PhysiciansHospitalist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI110E011830OtherSCHOENHERR BCBS GR PIN
MI4749053Medicaid
MI700E001650OtherWARREN BCBS GR PIN
MA1105009572OtherBCBSMI PERSONAL PIN
MI200158731OtherWARREN TAX ID
MI381898230OtherSCHOENHERR TAX ID
FLME111706OtherFLORIDA MEDICAL LICENSE
MI4216940Medicaid
MA1105009572OtherBCBSMI PERSONAL PIN
MIP28360006Medicare PIN
MI4216940Medicaid