MEDICARE: MS. ANNA LISA MATUDIO MS, OTR/L

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	225XP0200X	Pediatric Occupational Therapist	11757	CA

General Provider Information

NPI Number	:	1134473846
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. ANNA LISA MATUDIO MS, OTR/L

Provider Business Mailing Address
First Line	:	2033 NUNES DR
Second Line	:
City	:	SAN JOSE
State	:	CA
Zip	:	95131-2626
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	180 GRAND AVE
Second Line	:	SUITE 300
City	:	OAKLAND
State	:	CA
Zip	:	94612-3741
Country	:	US
Telephone Number	:	510-835-2131
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	11/01/2012
Last Update Date	:	11/01/2012

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