Healthcare Provider Details

I. General information

NPI: 1871527390
Provider Name (Legal Business Name): LESLIE A MATSUKAWA M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/10/2006
Last Update Date: 07/21/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

525 W OAK ST
FORT COLLINS CO
80521-2612
US

IV. Provider business mailing address

125 CRESTRIDGE ST
FORT COLLINS CO
80525-3934
US

V. Phone/Fax

Practice location:
  • Phone: 970-494-4200
  • Fax:
Mailing address:
  • Phone: 970-494-4200
  • Fax: 970-377-0967

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License NumberDR.0057723
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: