Provider Demographics
NPI:1225187222
Name:MATSUMOTO, KEN (MD)
Entity Type:Individual
Prefix:
First Name:KEN
Middle Name:
Last Name:MATSUMOTO
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1700 LANAKILA AVE
Mailing Address - Street 2:
Mailing Address - City:HONOLULU
Mailing Address - State:HI
Mailing Address - Zip Code:96817-2115
Mailing Address - Country:US
Mailing Address - Phone:808-832-3823
Mailing Address - Fax:808-832-5850
Practice Address - Street 1:1700 LANAKILA AVE
Practice Address - Street 2:
Practice Address - City:HONOLULU
Practice Address - State:HI
Practice Address - Zip Code:96817-2115
Practice Address - Country:US
Practice Address - Phone:808-832-3823
Practice Address - Fax:808-832-5850
Is Sole Proprietor?:No
Enumeration Date:2007-01-09
Last Update Date:2008-06-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
HIMD-98512084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
HIH52479Medicare ID - Type UnspecifiedMEDICARE