Provider Demographics
NPI:1538233572
Name:TERUYA, THEODORE H (MD)
Entity type:Individual
Prefix:DR
First Name:THEODORE
Middle Name:H
Last Name:TERUYA
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11370 ANDERSON ST
Mailing Address - Street 2:SUITE 2100
Mailing Address - City:LOMA LINDA
Mailing Address - State:CA
Mailing Address - Zip Code:92354-3450
Mailing Address - Country:US
Mailing Address - Phone:909-558-2126
Mailing Address - Fax:909-558-2401
Practice Address - Street 1:11370 ANDERSON ST
Practice Address - Street 2:SUITE 2100
Practice Address - City:LOMA LINDA
Practice Address - State:CA
Practice Address - Zip Code:92354-3450
Practice Address - Country:US
Practice Address - Phone:909-558-2126
Practice Address - Fax:909-558-2401
Is Sole Proprietor?:No
Enumeration Date:2006-11-20
Last Update Date:2023-06-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
HI10795208600000X, 2086S0129X
CAA719122086S0129X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2086S0129XAllopathic & Osteopathic PhysiciansSurgeryVascular Surgery
No208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
55759801OtherALOHACARE
990287995OtherUHA
990287995OtherVET ADMIN
990287995OtherPAC ADMIN
0000249011OtherHMSA
HI55759801Medicaid
990287995OtherAETNA
990287995OtherCYRCA
990287995OtherUHC
990287995OtherTRICARE
990287995OtherDMBA
990287995OtherHMAA
990287995OtherHPMR
990287995OtherHMA
MD10795OtherMDX
517420OtherHMA NEW
990287995OtherDMBA
57610Medicare ID - Type Unspecified