Provider Demographics
NPI:1215407499
Name:MATSUURA, JUSTIN SCOTT (OD)
Entity Type:Individual
Prefix:DR
First Name:JUSTIN
Middle Name:SCOTT
Last Name:MATSUURA
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 1:7898 BROADWAY
Mailing Address - Street 2:
Mailing Address - City:LEMON GROVE
Mailing Address - State:CA
Mailing Address - Zip Code:91945-1801
Mailing Address - Country:US
Mailing Address - Phone:619-464-7713
Mailing Address - Fax:
Practice Address - Street 1:7898 BROADWAY
Practice Address - Street 2:
Practice Address - City:LEMON GROVE
Practice Address - State:CA
Practice Address - Zip Code:91945-1801
Practice Address - Country:US
Practice Address - Phone:619-464-7713
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-11-29
Last Update Date:2018-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA34023TLG152WP0200X, 152WC0802X, 152WS0006X, 152WV0400X, 152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
No152WP0200XEye and Vision Services ProvidersOptometristPediatrics
No152WC0802XEye and Vision Services ProvidersOptometristCorneal and Contact Management
No152WS0006XEye and Vision Services ProvidersOptometristSports Vision
No152WV0400XEye and Vision Services ProvidersOptometristVision Therapy