Provider Demographics
NPI:1578200903
Name:IDE, TOMOHIRO
Entity Type:Individual
Prefix:
First Name:TOMOHIRO
Middle Name:
Last Name:IDE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6001 DODGE ST HEALTH AND KINESIOLOGY 207
Mailing Address - Street 2:
Mailing Address - City:OMAHA
Mailing Address - State:NE
Mailing Address - Zip Code:68182-0001
Mailing Address - Country:US
Mailing Address - Phone:531-218-9130
Mailing Address - Fax:
Practice Address - Street 1:6001 DODGE ST SAPP FIELDHOUSE
Practice Address - Street 2:
Practice Address - City:OMAHA
Practice Address - State:NE
Practice Address - Zip Code:68182-0001
Practice Address - Country:US
Practice Address - Phone:531-218-9130
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-05-17
Last Update Date:2022-05-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer