Healthcare Provider Details

I. General information

NPI: 1679551204
Provider Name (Legal Business Name): GORDON T MATSUDA MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/04/2006
Last Update Date: 01/30/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3434 47TH ST SUITE 101
BOULDER CO
80301-1880
US

IV. Provider business mailing address

3434 47TH ST SUITE 101
BOULDER CO
80301-1880
US

V. Phone/Fax

Practice location:
  • Phone: 303-444-0840
  • Fax: 303-444-0838
Mailing address:
  • Phone: 303-444-0840
  • Fax: 303-444-0838

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208800000X
TaxonomyUrology Physician
License Number20793
License Number StateCO

VII. Legacy identifiers

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

# 1
Identifier29504074
Identifier TypeMEDICAID
Identifier StateCO
Identifier Issuer

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: