Provider Demographics
NPI:1477557494
Name:MATSUMOTO, BERTRAM T (MD)
Entity Type:Individual
Prefix:
First Name:BERTRAM
Middle Name:T
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 1:3200 S COUNTRY CLUB WAY
Mailing Address - Street 2:
Mailing Address - City:TEMPE
Mailing Address - State:AZ
Mailing Address - Zip Code:85282-4054
Mailing Address - Country:US
Mailing Address - Phone:480-839-0206
Mailing Address - Fax:480-839-0208
Practice Address - Street 1:3200 S COUNTRY CLUB WAY
Practice Address - Street 2:
Practice Address - City:TEMPE
Practice Address - State:AZ
Practice Address - Zip Code:85282-4054
Practice Address - Country:US
Practice Address - Phone:480-839-0206
Practice Address - Fax:480-839-0208
Is Sole Proprietor?:No
Enumeration Date:2005-06-08
Last Update Date:2011-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ24096207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZAZ0393470OtherBCBS AZ
AZ358988Medicaid
AZ6536800OtherCIGNA
AZAZ0393470OtherBCBS AZ
AZ01WCJCC05Medicare ID - Type Unspecified