Provider Demographics
NPI:1366858953
Name:MATSUMOTO, KEITH TSUGIO (MD)
Entity Type:Individual
Prefix:MR
First Name:KEITH
Middle Name:TSUGIO
Last Name:MATSUMOTO
Suffix:
Gender:M
Credentials:MD
Other - Prefix:MR
Other - First Name:KEITH
Other - Middle Name:TSUGIO
Other - Last Name:MATSUMOTO
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:1319 PUNAHOU STREET
Mailing Address - Street 2:SUITE 900
Mailing Address - City:HONOLULU
Mailing Address - State:HI
Mailing Address - Zip Code:96826-1032
Mailing Address - Country:US
Mailing Address - Phone:808-949-0011
Mailing Address - Fax:808-943-2536
Practice Address - Street 1:1319 PUNAHOU STREET
Practice Address - Street 2:SUITE 9000
Practice Address - City:HONOLULU
Practice Address - State:HI
Practice Address - Zip Code:96826-1032
Practice Address - Country:US
Practice Address - Phone:808-949-0011
Practice Address - Fax:808-943-2536
Is Sole Proprietor?:Yes
Enumeration Date:2014-07-03
Last Update Date:2014-07-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
HI4464208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics