=====================================================
General NPI Number Information
=====================================================
NPI Number | 1255463071
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | GARY MATSUMURA MD A PROFESSIONAL MEDICAL CORPORATION
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/09/2007
-----------------------------------------------------
Last Update Date | 11/08/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1817 ROCKVILLE ROAD
-----------------------------------------------------
City | FAIRFIED
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 94534-1412
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 707-695-8000
-----------------------------------------------------
Fax | 707-864-3506
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 1862
-----------------------------------------------------
City | SUISUN CITY
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 94585
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 707-695-8000
-----------------------------------------------------
Fax | 707-864-3506
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | GARY ARTHUR MATSUMURA
-----------------------------------------------------
Credential | MD
-----------------------------------------------------
Telephone | 707-695-8000
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207V00000X
-----------------------------------------------------
Taxonomy Name | Obstetrics & Gynecology Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------