Healthcare Provider Details

I. General information

NPI: 1659454635
Provider Name (Legal Business Name): KEITH T MATSUMOTO MD INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/23/2006
Last Update Date: 06/19/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1319 PUNAHOU ST SUITE 900
HONOLULU HI
96826-1032
US

IV. Provider business mailing address

1319 PUNAHOU ST 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: KEITH TSUGIO MATSUMOTO
Title or Position: PRESIDENT
Credential: MD
Phone: 808-949-0011