Healthcare Provider Details

I. General information

NPI: 1477576239
Provider Name (Legal Business Name): SUSAN E OMURA MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/25/2006
Last Update Date: 04/25/2025
Certification Date: 04/25/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

25050 SE STARK ST STE 300
GRESHAM OR
97030-3388
US

IV. Provider business mailing address

3454 NE HASSALO ST
PORTLAND OR
97232-2527
US

V. Phone/Fax

Practice location:
  • Phone: 503-667-8878
  • Fax: 503-667-0310
Mailing address:
  • Phone: 503-490-8155
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207PP0204X
TaxonomyPediatric Emergency Medicine (Emergency Medicine) Physician
License NumberMD23697
License Number StateOR
# 2
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberMD23697
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: