Provider Demographics
NPI:1124041801
Name:NISHIO, MATTHEW MAKOTO (OD)
Entity Type:Individual
Prefix:
First Name:MATTHEW
Middle Name:MAKOTO
Last Name:NISHIO
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6782 ALAMAR WAY
Mailing Address - Street 2:
Mailing Address - City:ELK GROVE
Mailing Address - State:CA
Mailing Address - Zip Code:95758-6273
Mailing Address - Country:US
Mailing Address - Phone:916-684-1827
Mailing Address - Fax:
Practice Address - Street 1:4433 FLORIN RD
Practice Address - Street 2:SUITE 890
Practice Address - City:SACRAMENTO
Practice Address - State:CA
Practice Address - Zip Code:95823-2527
Practice Address - Country:US
Practice Address - Phone:906-393-5151
Practice Address - Fax:916-392-6130
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-25
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA11432T152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CASD011432Medicaid
CASD011432Medicaid