Healthcare Provider Details

I. General information

NPI: 1538233572
Provider Name (Legal Business Name): THEODORE H TERUYA MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/20/2006
Last Update Date: 06/29/2023
Certification Date: 06/29/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11370 ANDERSON ST SUITE 2100
LOMA LINDA CA
92354-3450
US

IV. Provider business mailing address

11370 ANDERSON ST SUITE 2100
LOMA LINDA CA
92354-3450
US

V. Phone/Fax

Practice location:
  • Phone: 909-558-2126
  • Fax: 909-558-2401
Mailing address:
  • Phone: 909-558-2126
  • Fax: 909-558-2401

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number10795
License Number StateHI
# 2
Primary TaxonomyN
Taxonomy Code2086S0129X
TaxonomyVascular Surgery Physician
License Number10795
License Number StateHI
# 3
Primary TaxonomyY
Taxonomy Code2086S0129X
TaxonomyVascular Surgery Physician
License NumberA71912
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: