Healthcare Provider Details

I. General information

NPI: 1477557494
Provider Name (Legal Business Name): BERTRAM T MATSUMOTO MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/08/2005
Last Update Date: 10/31/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3200 S COUNTRY CLUB WAY
TEMPE AZ
85282-4054
US

IV. Provider business mailing address

3200 S COUNTRY CLUB WAY
TEMPE AZ
85282-4054
US

V. Phone/Fax

Practice location:
  • Phone: 480-839-0206
  • Fax: 480-839-0208
Mailing address:
  • Phone: 480-839-0206
  • Fax: 480-839-0208

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207W00000X
TaxonomyOphthalmology Physician
License Number24096
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: