Provider Demographics
NPI:1336163732
Name:OMIYA, BRUCE HIROSHI (MD)
Entity Type:Individual
Prefix:DR
First Name:BRUCE
Middle Name:HIROSHI
Last Name:OMIYA
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5528 E LA PALMA AVE
Mailing Address - Street 2:SUITE 4-A
Mailing Address - City:ANAHEIM
Mailing Address - State:CA
Mailing Address - Zip Code:92807-2115
Mailing Address - Country:US
Mailing Address - Phone:714-970-0200
Mailing Address - Fax:714-970-0270
Practice Address - Street 1:5528 E LA PALMA AVE
Practice Address - Street 2:SUITE 4-A
Practice Address - City:ANAHEIM
Practice Address - State:CA
Practice Address - Zip Code:92807-2115
Practice Address - Country:US
Practice Address - Phone:714-970-0200
Practice Address - Fax:714-970-0270
Is Sole Proprietor?:No
Enumeration Date:2006-07-27
Last Update Date:2014-04-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA433522085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A433520Medicaid
CAE99169Medicare UPIN
CA00A433520Medicare PIN
CAWA43352JMedicare PIN
CA00A433520Medicaid
CAWA43352GMedicare PIN
CAWA43352AMedicare PIN