Basic Information
| Provider Information | |||||||||
| NPI: | 1790720019 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MUKUNO | ||||||||
| FirstName: | DWIGHT | ||||||||
| MiddleName: | HISAYUKI | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3160 FOLSOM BLVD | ||||||||
| Address2: | |||||||||
| City: | SACRAMENTO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 958165219 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9167335701 | ||||||||
| FaxNumber: | 9167333401 | ||||||||
| Practice Location | |||||||||
| Address1: | 6305 COYLE AVE | ||||||||
| Address2: | |||||||||
| City: | CARMICHAEL | ||||||||
| State: | CA | ||||||||
| PostalCode: | 956080438 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9169616920 | ||||||||
| FaxNumber: | 9169665063 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/19/2006 | ||||||||
| LastUpdateDate: | 08/21/2007 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085B0100X | G40177 | CA | N | Allopathic & Osteopathic Physicians | Radiology | Body Imaging | 2085R0202X | G40177 | CA | Y | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology |
ID Information
| ID | Type | State | Issuer | Description | 00G401770 | 01 | CA | MEDI-CAL | OTHER | P00176690 | 01 | RAILROAD MEDICARE | OTHER |