Provider Demographics
NPI:1336628080
Name:MIZOGUCHI, TSETEN
Entity Type:Individual
Prefix:DR
First Name:TSETEN
Middle Name:
Last Name:MIZOGUCHI
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:150 E YORBA LINDA BLVD
Mailing Address - Street 2:
Mailing Address - City:PLACENTIA
Mailing Address - State:CA
Mailing Address - Zip Code:92870-3327
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:150 E YORBA LINDA BLVD
Practice Address - Street 2:
Practice Address - City:PLACENTIA
Practice Address - State:CA
Practice Address - Zip Code:92870-3327
Practice Address - Country:US
Practice Address - Phone:714-528-3112
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-08-13
Last Update Date:2018-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA42802183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA18Medicaid