Healthcare Provider Details

I. General information

NPI: 1033030408
Provider Name (Legal Business Name): OMED KAZUHARU THURSTON
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

Provider Other Name: KAZU THURSTON

II. Dates (important events)

Enumeration Date: 07/22/2026
Last Update Date: 07/22/2026
Certification Date: 07/22/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2060 OTAY LAKES RD STE 110
CHULA VISTA CA
91913-1364
US

IV. Provider business mailing address

9620 ORANGEBURG CT
SAN DIEGO CA
92129-3519
US

V. Phone/Fax

Practice location:
  • Phone: 619-373-9222
  • Fax:
Mailing address:
  • Phone: 619-655-6025
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2251X0800X
TaxonomyOrthopedic Physical Therapist
License Number310261
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: