Healthcare Provider Details

I. General information

NPI: 1871912451
Provider Name (Legal Business Name): RONALD HIROTSUGU OMINO M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/10/2014
Last Update Date: 12/16/2020
Certification Date: 12/16/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2655 1ST ST STE 360
SIMI VALLEY CA
93065-1581
US

IV. Provider business mailing address

5767 W CENTURY BLVD STE 400
LOS ANGELES CA
90045-5631
US

V. Phone/Fax

Practice location:
  • Phone: 805-583-7640
  • Fax:
Mailing address:
  • Phone: 310-301-8771
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207RG0100X
TaxonomyGastroenterology Physician
License NumberA166989
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberBP10049474
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: