Provider Demographics
NPI:1730386145
Name:MIZUHARA-CHENG, COURTNEY TAMIKO (DO)
Entity type:Individual
Prefix:
First Name:COURTNEY
Middle Name:TAMIKO
Last Name:MIZUHARA-CHENG
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2901 OCEAN PARK BLVD STE 207
Mailing Address - Street 2:
Mailing Address - City:SANTA MONICA
Mailing Address - State:CA
Mailing Address - Zip Code:90405-2964
Mailing Address - Country:US
Mailing Address - Phone:424-272-6513
Mailing Address - Fax:
Practice Address - Street 1:2901 OCEAN PARK BLVD STE 207
Practice Address - Street 2:
Practice Address - City:SANTA MONICA
Practice Address - State:CA
Practice Address - Zip Code:90405-2964
Practice Address - Country:US
Practice Address - Phone:424-272-6513
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-06-29
Last Update Date:2016-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA20A10710207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine