Provider Demographics
NPI:1609527613
Name:SHIYOMURA, KEIJI JAY (OD)
Entity Type:Individual
Prefix:DR
First Name:KEIJI
Middle Name:JAY
Last Name:SHIYOMURA
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:61535 S HIGHWAY 97 STE 16
Mailing Address - Street 2:
Mailing Address - City:BEND
Mailing Address - State:OR
Mailing Address - Zip Code:97702-2156
Mailing Address - Country:US
Mailing Address - Phone:541-389-4774
Mailing Address - Fax:541-389-3971
Practice Address - Street 1:61535 S HIGHWAY 97 STE 16
Practice Address - Street 2:
Practice Address - City:BEND
Practice Address - State:OR
Practice Address - Zip Code:97702-2156
Practice Address - Country:US
Practice Address - Phone:541-389-4774
Practice Address - Fax:541-389-3971
Is Sole Proprietor?:Yes
Enumeration Date:2022-01-11
Last Update Date:2024-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORATI4607152WV0400X, 152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
No152WV0400XEye and Vision Services ProvidersOptometristVision Therapy