Provider Demographics
NPI:1275528721
Name:MATSUMOTO, LARRY (MD)
Entity Type:Individual
Prefix:
First Name:LARRY
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:PO BOX 2311
Mailing Address - Street 2:
Mailing Address - City:CHATSWORTH
Mailing Address - State:CA
Mailing Address - Zip Code:91313-2311
Mailing Address - Country:US
Mailing Address - Phone:818-718-9500
Mailing Address - Fax:818-718-9507
Practice Address - Street 1:2105 FOREST AVE
Practice Address - Street 2:
Practice Address - City:SAN JOSE
Practice Address - State:CA
Practice Address - Zip Code:95128-1425
Practice Address - Country:US
Practice Address - Phone:408-947-2501
Practice Address - Fax:408-283-7745
Is Sole Proprietor?:No
Enumeration Date:2005-09-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG25060207ZP0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ZP0102XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology & Clinical Pathology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G250600Medicaid
CA00G250600Medicaid
CA00G250600Medicare ID - Type Unspecified