Basic Information
| Provider Information | |||||||||
| NPI: | 1720063217 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | NOMURA | ||||||||
| FirstName: | ROY | ||||||||
| MiddleName: | M.Y. | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 1280 MERCANTILE DR | ||||||||
| Address2: | |||||||||
| City: | HIGHLAND | ||||||||
| State: | IL | ||||||||
| PostalCode: | 622491256 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6186548985 | ||||||||
| FaxNumber: | 6186548650 | ||||||||
| Practice Location | |||||||||
| Address1: | 1270 MERCANTILE DR | ||||||||
| Address2: | |||||||||
| City: | HIGHLAND | ||||||||
| State: | IL | ||||||||
| PostalCode: | 622491256 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6186518097 | ||||||||
| FaxNumber: | 6186518097 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/07/2005 | ||||||||
| LastUpdateDate: | 07/22/2008 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | M | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207ZP0105X | 036043088 | IL | Y | Allopathic & Osteopathic Physicians | Pathology | Clinical Pathology/Laboratory Medicine |
ID Information
| ID | Type | State | Issuer | Description | CK0761 | 01 | IL | RR MEDICARE PIN | OTHER |