Healthcare Provider Details

I. General information

NPI: 1609527613
Provider Name (Legal Business Name): KEIJI JAY SHIYOMURA OD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/11/2022
Last Update Date: 02/15/2024
Certification Date: 02/15/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

61535 S HIGHWAY 97 STE 16
BEND OR
97702-2156
US

IV. Provider business mailing address

61535 S HIGHWAY 97 STE 16
BEND OR
97702-2156
US

V. Phone/Fax

Practice location:
  • Phone: 541-389-4774
  • Fax: 541-389-3971
Mailing address:
  • Phone: 541-389-4774
  • Fax: 541-389-3971

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code152WV0400X
TaxonomyVision Therapy Optometrist
License NumberATI4607
License Number StateOR
# 2
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License NumberATI4607
License Number StateOR

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: