Provider Demographics
NPI:1376596221
Name:MATSUMURA, JERRY S (MD)
Entity Type:Individual
Prefix:
First Name:JERRY
Middle Name:S
Last Name:MATSUMURA
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
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Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:18124 WEDGE PKWY STE 232
Mailing Address - Street 2:
Mailing Address - City:RENO
Mailing Address - State:NV
Mailing Address - Zip Code:89511-8134
Mailing Address - Country:US
Mailing Address - Phone:801-993-9534
Mailing Address - Fax:775-853-2728
Practice Address - Street 1:18124 WEDGE PKWY STE 232
Practice Address - Street 2:
Practice Address - City:RENO
Practice Address - State:NV
Practice Address - Zip Code:89511-8134
Practice Address - Country:US
Practice Address - Phone:888-280-0379
Practice Address - Fax:775-853-2728
Is Sole Proprietor?:No
Enumeration Date:2006-05-19
Last Update Date:2008-02-01
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
NV7899207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NVV100541Medicare PIN