Provider Demographics
NPI:1912279787
Name:NISHIMURA, TED KIYOTOSHI (OD)
Entity Type:Individual
Prefix:DR
First Name:TED
Middle Name:KIYOTOSHI
Last Name:NISHIMURA
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5175 DAWES AVE
Mailing Address - Street 2:
Mailing Address - City:CULVER CITY
Mailing Address - State:CA
Mailing Address - Zip Code:90230-6011
Mailing Address - Country:US
Mailing Address - Phone:310-398-9076
Mailing Address - Fax:
Practice Address - Street 1:1051 W BURBANK BLVD
Practice Address - Street 2:
Practice Address - City:BURBANK
Practice Address - State:CA
Practice Address - Zip Code:91506-1421
Practice Address - Country:US
Practice Address - Phone:818-841-7055
Practice Address - Fax:818-841-7058
Is Sole Proprietor?:No
Enumeration Date:2012-02-08
Last Update Date:2012-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA10983T152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist