MEDICARE: DR. IAN M MATSUURA M.D.

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	2085R0202X	Diagnostic Radiology Physician	ME85147	FL
2	2085R0202X	Diagnostic Radiology Physician	G84323	CA

General Provider Information

NPI Number	:	1447200266
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. IAN M MATSUURA M.D.

Provider Business Mailing Address
First Line	:	11995 SINGLETREE LN
Second Line	:	SUITE 500
City	:	EDEN PRAIRIE
State	:	MN
Zip	:	55344-5347
Country	:	US
Telephone Number	:	952-595-1301
Fax Number	:	612-294-4903

Provider Business Practice Location Address
First Line	:	207 PALISADES AVE
Second Line	:
City	:	SANTA MONICA
State	:	CA
Zip	:	90402-2733
Country	:	US
Telephone Number	:	952-595-1100
Fax Number	:	614-294-4903

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

Provider Enumeration Date	:	05/11/2006
Last Update Date	:	11/12/2014

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