Provider Demographics
NPI:1902054737
Name:TSURUDOME, MITCHELL (DPT)
Entity Type:Individual
Prefix:DR
First Name:MITCHELL
Middle Name:
Last Name:TSURUDOME
Suffix:
Gender:M
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16420 S HARVARD BLVD
Mailing Address - Street 2:UNIT 1
Mailing Address - City:GARDENA
Mailing Address - State:CA
Mailing Address - Zip Code:90247-4773
Mailing Address - Country:US
Mailing Address - Phone:310-538-4725
Mailing Address - Fax:
Practice Address - Street 1:16420 S HARVARD BLVD
Practice Address - Street 2:UNIT 1
Practice Address - City:GARDENA
Practice Address - State:CA
Practice Address - Zip Code:90247-4773
Practice Address - Country:US
Practice Address - Phone:310-538-4725
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-09-05
Last Update Date:2008-09-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA26175225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist