Provider Demographics
NPI:1205837986
Name:OMURA, TED H (DC)
Entity Type:Individual
Prefix:
First Name:TED
Middle Name:H
Last Name:OMURA
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1609 MERIDIAN AVE
Mailing Address - Street 2:
Mailing Address - City:SAN JOSE
Mailing Address - State:CA
Mailing Address - Zip Code:95125-5532
Mailing Address - Country:US
Mailing Address - Phone:408-448-8818
Mailing Address - Fax:
Practice Address - Street 1:1609 MERIDIAN AVE
Practice Address - Street 2:
Practice Address - City:SAN JOSE
Practice Address - State:CA
Practice Address - Zip Code:95125-5532
Practice Address - Country:US
Practice Address - Phone:408-448-8818
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2005-08-03
Last Update Date:2010-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CADC025988111NS0005X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111NS0005XChiropractic ProvidersChiropractorSports Physician
Provider Identifiers
StateIdentifier IDID TypeIssuer
CADC0259880OtherBLUE SHIELD
CA357446700OtherDEPT. OF LABOR
CA5708678OtherAETNA
CA5708678OtherAETNA
CADC0259880Medicare ID - Type UnspecifiedMEDICARE