Provider Demographics
NPI:1922015445
Name:NIIZAWA, JEFFREY MORITO (MD)
Entity Type:Individual
Prefix:
First Name:JEFFREY
Middle Name:MORITO
Last Name:NIIZAWA
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 689022
Mailing Address - Street 2:
Mailing Address - City:FRANKLIN
Mailing Address - State:TN
Mailing Address - Zip Code:37068-9022
Mailing Address - Country:US
Mailing Address - Phone:615-465-7672
Mailing Address - Fax:615-469-6512
Practice Address - Street 1:2020 SILVER CREEK RD
Practice Address - Street 2:SUITE 220
Practice Address - City:BULLHEAD CITY
Practice Address - State:AZ
Practice Address - Zip Code:86442-8476
Practice Address - Country:US
Practice Address - Phone:928-763-2500
Practice Address - Fax:928-763-0027
Is Sole Proprietor?:No
Enumeration Date:2006-08-01
Last Update Date:2021-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ21760207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ2Z7711OtherHEALTH NET OF AZ
AZ4402714OtherAETNA
AZ3520720OtherCIGNA
AZ148024Medicaid
AZ3520720OtherCIGNA
AZ4402714OtherAETNA
AZ148024Medicaid
AZZ119552Medicare PIN