MEDICARE: TED H. OMURA DC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	111NS0005X	Sports Physician Chiropractor	DC025988	CA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	DC0259880	OTHER	CA	BLUE SHIELD
2	357446700	OTHER	CA	DEPT. OF LABOR
3	5708678	OTHER	CA	AETNA

General Provider Information

NPI Number	:	1205837986
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	TED H. OMURA DC

Provider Business Mailing Address
First Line	:	1609 MERIDIAN AVE
Second Line	:
City	:	SAN JOSE
State	:	CA
Zip	:	95125-5532
Country	:	US
Telephone Number	:	408-448-8818
Fax Number	:

Provider Business Practice Location Address
First Line	:	1609 MERIDIAN AVE
Second Line	:
City	:	SAN JOSE
State	:	CA
Zip	:	95125-5532
Country	:	US
Telephone Number	:	408-448-8818
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/03/2005
Last Update Date	:	09/09/2010

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Directions to “ TED H. OMURA DC” Practice Location

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