Provider Demographics
NPI:1881656254
Name:MIZUBA, ERIC S (DC)
Entity Type:Individual
Prefix:DR
First Name:ERIC
Middle Name:S
Last Name:MIZUBA
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:65-1206 MAMALAHOA HWY STE 3-12
Mailing Address - Street 2:
Mailing Address - City:KAMUELA
Mailing Address - State:HI
Mailing Address - Zip Code:96743-7303
Mailing Address - Country:US
Mailing Address - Phone:814-490-3104
Mailing Address - Fax:814-833-9355
Practice Address - Street 1:65-1206 MAMALAHOA HWY STE 3-12
Practice Address - Street 2:
Practice Address - City:KAMUELA
Practice Address - State:HI
Practice Address - Zip Code:96743-7303
Practice Address - Country:US
Practice Address - Phone:814-490-3104
Practice Address - Fax:814-833-9355
Is Sole Proprietor?:Yes
Enumeration Date:2006-04-03
Last Update Date:2018-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADC007380L111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA001786492/0002Medicaid
PA001786492/0002Medicaid
PAMI034691Medicare ID - Type Unspecified