Provider Demographics
NPI:1710936612
Name:OMURA, NAYOMI ELLEN (MD)
Entity Type:Individual
Prefix:
First Name:NAYOMI
Middle Name:ELLEN
Last Name:OMURA
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:600 VILLAGE SQUARE XING
Mailing Address - Street 2:
Mailing Address - City:PALM BEACH GARDENS
Mailing Address - State:FL
Mailing Address - Zip Code:33410-4542
Mailing Address - Country:US
Mailing Address - Phone:561-694-9493
Mailing Address - Fax:
Practice Address - Street 1:2601 S KANNER HWY
Practice Address - Street 2:
Practice Address - City:STUART
Practice Address - State:FL
Practice Address - Zip Code:34994-4622
Practice Address - Country:US
Practice Address - Phone:772-219-2777
Practice Address - Fax:772-219-0017
Is Sole Proprietor?:No
Enumeration Date:2006-05-08
Last Update Date:2021-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME85895207ND0101X, 207NS0135X, 207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
No207ND0101XAllopathic & Osteopathic PhysiciansDermatologyMOHS-Micrographic Surgery
No207NS0135XAllopathic & Osteopathic PhysiciansDermatologyProcedural Dermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLU0420ZMedicare ID - Type Unspecified
FLH19621Medicare UPIN
FLU0420YMedicare ID - Type Unspecified
FLU0420WMedicare ID - Type Unspecified
FLU0420VMedicare ID - Type Unspecified
FLU0420XMedicare ID - Type Unspecified