MEDICARE: DR. KYLE SHIGERU MATSUMURA MD

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	208VP0014X	Interventional Pain Medicine Physician	951306801205	UT

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	G79891	OTHER	UT	CAL MEDICAL LICENSE #
3	951306801205	OTHER	UT	UTAH MEDICAL LICENSE #

General Provider Information

NPI Number	:	1619907490
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. KYLE SHIGERU MATSUMURA MD

Provider Business Mailing Address
First Line	:	6750 S HIGHLAND DRIVE
Second Line	:	STE 100
City	:	COTTONWOOD HEIGHTS
State	:	UT
Zip	:	84121
Country	:	US
Telephone Number	:	801-685-7246
Fax Number	:	801-747-5487

Provider Business Practice Location Address
First Line	:	6750 S HIGHLAND DRIVE
Second Line	:	STE 100
City	:	COTTONWOOD HEIGHTS
State	:	UT
Zip	:	84121
Country	:	US
Telephone Number	:	801-685-7246
Fax Number	:	801-747-5487

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

Provider Enumeration Date	:	07/04/2006
Last Update Date	:	03/07/2023

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