Provider Demographics
NPI:1255612826
Name:MITSUMOTO, JUN MICHAEL (MD, MPH)
Entity type:Individual
Prefix:DR
First Name:JUN
Middle Name:MICHAEL
Last Name:MITSUMOTO
Suffix:
Gender:M
Credentials:MD, MPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:726 BROADWAY FL 3
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10003-9616
Mailing Address - Country:US
Mailing Address - Phone:212-443-1000
Mailing Address - Fax:212-446-1646
Practice Address - Street 1:726 BROADWAY FL 3
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10003-9580
Practice Address - Country:US
Practice Address - Phone:212-443-1000
Practice Address - Fax:212-446-1646
Is Sole Proprietor?:No
Enumeration Date:2011-09-08
Last Update Date:2024-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY268078207Q00000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program