MEDICARE: DR. GARY L. MATSON JR. D.O.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207Q00000X	Family Medicine Physician	20A6263	CA

General Provider Information

NPI Number	:	1154344695
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. GARY L. MATSON JR. D.O.

Provider Business Mailing Address
First Line	:	4501 MISSION BAY DR
Second Line	:	SUITE 3E
City	:	SAN DIEGO
State	:	CA
Zip	:	92109-4923
Country	:	US
Telephone Number	:	858-270-4343
Fax Number	:	858-272-1731

Provider Business Practice Location Address
First Line	:	4501 MISSION BAY DR
Second Line	:	SUITE 3E
City	:	SAN DIEGO
State	:	CA
Zip	:	92109-4923
Country	:	US
Telephone Number	:	858-270-4343
Fax Number	:	858-272-1731

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/25/2006
Last Update Date	:	07/08/2007

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