Provider Demographics
NPI:1477576239
Name:OMURA, SUSAN E (MD)
Entity type:Individual
Prefix:
First Name:SUSAN
Middle Name:E
Last Name:OMURA
Suffix:
Gender:
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3454 NE HASSALO ST
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97232-2527
Mailing Address - Country:US
Mailing Address - Phone:503-490-8155
Mailing Address - Fax:
Practice Address - Street 1:25050 SE STARK ST STE 300
Practice Address - Street 2:
Practice Address - City:GRESHAM
Practice Address - State:OR
Practice Address - Zip Code:97030-3388
Practice Address - Country:US
Practice Address - Phone:503-667-8878
Practice Address - Fax:503-667-0310
Is Sole Proprietor?:No
Enumeration Date:2006-07-25
Last Update Date:2025-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORMD23697207PP0204X, 208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
No207PP0204XAllopathic & Osteopathic PhysiciansEmergency MedicinePediatric Emergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR286909Medicaid
OR286909Medicaid