Provider Demographics
NPI:1225357833
Name:GARY L MATSON DO INC
Entity Type:Organization
Organization Name:GARY L MATSON DO INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:GARY
Authorized Official - Middle Name:L
Authorized Official - Last Name:MATSON
Authorized Official - Suffix:JR
Authorized Official - Credentials:DO
Authorized Official - Phone:858-270-4343
Mailing Address - Street 1:4501 MISSION BAY DR 3E
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92109
Mailing Address - Country:US
Mailing Address - Phone:858-270-4343
Mailing Address - Fax:858-272-1731
Practice Address - Street 1:4501 MISSION BAY DR 3E
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92109
Practice Address - Country:US
Practice Address - Phone:858-270-4343
Practice Address - Fax:858-272-1731
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-05-21
Last Update Date:2010-05-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA20A6263207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00AX62631Medicaid
CA00AX62631Medicaid