Provider Demographics
NPI:1164596979
Name:MATSUDA, GERALD M
Entity Type:Individual
Prefix:DR
First Name:GERALD
Middle Name:M
Last Name:MATSUDA
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:30 AULIKE ST
Mailing Address - Street 2:SUITE 102
Mailing Address - City:KAILUA
Mailing Address - State:HI
Mailing Address - Zip Code:96734-2707
Mailing Address - Country:US
Mailing Address - Phone:808-262-8107
Mailing Address - Fax:808-262-8108
Practice Address - Street 1:30 AULIKE ST
Practice Address - Street 2:SUITE 102
Practice Address - City:KAILUA
Practice Address - State:HI
Practice Address - Zip Code:96734-2707
Practice Address - Country:US
Practice Address - Phone:808-262-8107
Practice Address - Fax:808-262-8108
Is Sole Proprietor?:No
Enumeration Date:2006-11-20
Last Update Date:2012-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
HI184152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
HI01360601Medicaid
HIT41210Medicare UPIN
HIBY569ZMedicare PIN
HIBY562AMedicare PIN
HI0824380001Medicare NSC
HIH0000PGBCDMedicare PIN
HI01360601Medicaid
HIBY562BMedicare PIN