Healthcare Provider Details

I. General information

NPI: 1720223175
Provider Name (Legal Business Name): MICHAEL JOHN MATSUURA MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/12/2008
Last Update Date: 02/24/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

22 S GREENE ST
BALTIMORE MD
21201-1544
US

IV. Provider business mailing address

8716 POLISHED PEBBLE WAY
LAUREL MD
20723-5909
US

V. Phone/Fax

Practice location:
  • Phone: 410-328-6704
  • Fax:
Mailing address:
  • Phone: 410-328-6704
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208600000X
TaxonomySurgery Physician
License NumberD72797
License Number StateMD
# 2
Primary TaxonomyN
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License NumberMD-14431
License Number StateHI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: