Healthcare Provider Details

I. General information

NPI: 1336163732
Provider Name (Legal Business Name): BRUCE HIROSHI OMIYA M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/27/2006
Last Update Date: 04/17/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5528 E LA PALMA AVE SUITE 4-A
ANAHEIM CA
92807-2115
US

IV. Provider business mailing address

5528 E LA PALMA AVE SUITE 4-A
ANAHEIM CA
92807-2115
US

V. Phone/Fax

Practice location:
  • Phone: 714-970-0200
  • Fax: 714-970-0270
Mailing address:
  • Phone: 714-970-0200
  • Fax: 714-970-0270

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License NumberA43352
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: