Provider Demographics
NPI:1215039227
Name:MATSUMOTO, DIANE K (MD)
Entity Type:Individual
Prefix:MRS
First Name:DIANE
Middle Name:K
Last Name:MATSUMOTO
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16611 S 40TH ST
Mailing Address - Street 2:STE 160
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85048
Mailing Address - Country:US
Mailing Address - Phone:480-940-8527
Mailing Address - Fax:480-940-8530
Practice Address - Street 1:16611 S 40TH ST
Practice Address - Street 2:STE 160
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85048
Practice Address - Country:US
Practice Address - Phone:480-940-8527
Practice Address - Fax:480-940-8530
Is Sole Proprietor?:No
Enumeration Date:2006-09-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ24004208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ351510Medicaid