Healthcare Provider Details

I. General information

NPI: 1134148828
Provider Name (Legal Business Name): OSAMU H MATSUTANI M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/19/2006
Last Update Date: 10/01/2020
Certification Date: 10/01/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3260 PROVIDENCE DR C TOWER, SUITE 537
ANCHORAGE AK
99508-4661
US

IV. Provider business mailing address

PO BOX 4105
PORTLAND OR
97208-4105
US

V. Phone/Fax

Practice location:
  • Phone: 907-212-2673
  • Fax:
Mailing address:
  • Phone: 866-907-1068
  • Fax: 425-917-9141

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0804X
TaxonomyChild & Adolescent Psychiatry Physician
License Number1905
License Number StateAK

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier1010889
Identifier TypeMEDICAID
Identifier StateAK
Identifier Issuer

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: