Healthcare Provider Details

I. General information

NPI: 1780870956
Provider Name (Legal Business Name): MICHELLE CHIEMI OMURA M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/20/2007
Last Update Date: 01/14/2021
Certification Date: 01/14/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10111 HOLE AVE
RIVERSIDE CA
92503-3441
US

IV. Provider business mailing address

10111 HOLE AVE
RIVERSIDE CA
92503-3441
US

V. Phone/Fax

Practice location:
  • Phone: 951-352-0555
  • Fax:
Mailing address:
  • Phone: 310-985-4548
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License NumberA101365
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: