Provider Demographics
NPI:1154443166
Name:GERALD N. MATSUYAMA, O.D., LLC
Entity Type:Organization
Organization Name:GERALD N. MATSUYAMA, O.D., LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:GERALD
Authorized Official - Middle Name:N
Authorized Official - Last Name:MATSUYAMA
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:808-734-1988
Mailing Address - Street 1:1109 12TH AVE STE 103
Mailing Address - Street 2:
Mailing Address - City:HONOLULU
Mailing Address - State:HI
Mailing Address - Zip Code:96816-3714
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1109 12TH AVE STE 103
Practice Address - Street 2:
Practice Address - City:HONOLULU
Practice Address - State:HI
Practice Address - Zip Code:96816-3714
Practice Address - Country:US
Practice Address - Phone:808-734-1988
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-03
Last Update Date:2009-04-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
HI189152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
HI01409062Medicaid
0368800001Medicare NSC
H102504Medicare PIN