Basic Information
| Provider Information | |||||||||
| NPI: | 1336409820 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MIZUNAKA | ||||||||
| FirstName: | JOCELYN | ||||||||
| MiddleName: | ANN | ||||||||
| NamePrefix: | MRS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | FONG | ||||||||
| OtherFirstName: | JOCELYN | ||||||||
| OtherMiddleName: | ANN | ||||||||
| OtherNamePrefix: | MS. | ||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | MD | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 3875 W BEECHWOOD AVE | ||||||||
| Address2: | |||||||||
| City: | FRESNO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 937110795 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5598750557 | ||||||||
| FaxNumber: | 5598750575 | ||||||||
| Practice Location | |||||||||
| Address1: | 1570 7TH STREET | ||||||||
| Address2: | |||||||||
| City: | SANGER | ||||||||
| State: | CA | ||||||||
| PostalCode: | 93657 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5598750557 | ||||||||
| FaxNumber: | 5598750575 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/18/2012 | ||||||||
| LastUpdateDate: | 07/08/2020 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 07/08/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 18062 | HI | Y | Allopathic & Osteopathic Physicians | Family Medicine |
No ID Information.