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NPI Code Detail

MEDICARE: DOUGLAS TOM IMURA

MEDICARE: DOUGLAS TOM IMURA
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
1172V00000XCommunity Health Worker

General Provider Information

NPI Number : 1790213767
Entity Type Code : Individual
Provider Name (Legal Business Name) : DOUGLAS TOM IMURA
Provider Business Mailing Address
First Line : 300 HARBOR BLVD BLDG E
Second Line :
City : BELMONT
State : CA
Zip : 94002-4018
Country : US
Telephone Number : 650-380-6149
Fax Number : 650-952-5846
Provider Business Practice Location Address
First Line : 505 CYPRESS AVE
Second Line :
City : SOUTH SAN FRANCISCO
State : CA
Zip : 94080-2922
Country : US
Telephone Number : 650-380-6149
Fax Number : 650-952-5846
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 06/02/2017
Last Update Date : 06/02/2017

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Directions to “ DOUGLAS TOM IMURA ” Practice Location

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