Healthcare Provider Details

I. General information

NPI: 1366858953
Provider Name (Legal Business Name): KEITH TSUGIO MATSUMOTO M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

Provider Other Name: KEITH TSUGIO MATSUMOTO M.D.

II. Dates (important events)

Enumeration Date: 07/03/2014
Last Update Date: 07/03/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1319 PUNAHOU STREET SUITE 9000
HONOLULU HI
96826-1032
US

IV. Provider business mailing address

1319 PUNAHOU STREET SUITE 900
HONOLULU HI
96826-1032
US

V. Phone/Fax

Practice location:
  • Phone: 808-949-0011
  • Fax: 808-943-2536
Mailing address:
  • Phone: 808-949-0011
  • Fax: 808-943-2536

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number4464
License Number StateHI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: