Healthcare Provider Details

I. General information

NPI: 1770591562
Provider Name (Legal Business Name): JOHN HENRY MATSUURA MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/04/2006
Last Update Date: 04/30/2025
Certification Date: 04/30/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2300 MIAMI VALLEY DR STE 350
DAYTON OH
45459-1294
US

IV. Provider business mailing address

2300 MIAMI VALLEY DR STE 350
CENTERVILLE OH
45459-1294
US

V. Phone/Fax

Practice location:
  • Phone: 937-424-2469
  • Fax: 937-424-2479
Mailing address:
  • Phone: 937-438-8640
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2086S0129X
TaxonomyVascular Surgery Physician
License Number37403
License Number StateIA
# 2
Primary TaxonomyN
Taxonomy Code2086S0129X
TaxonomyVascular Surgery Physician
License NumberMD-20852
License Number StateHI
# 3
Primary TaxonomyY
Taxonomy Code2086S0129X
TaxonomyVascular Surgery Physician
License Number35.0575510
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: