Provider Demographics
NPI:1477818375
Name:MATZUMURA KUAN, MELISSA (MD)
Entity Type:Individual
Prefix:
First Name:MELISSA
Middle Name:
Last Name:MATZUMURA KUAN
Suffix:
Gender:F
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 2147
Mailing Address - Street 2:
Mailing Address - City:FORT MYERS
Mailing Address - State:FL
Mailing Address - Zip Code:33902-2147
Mailing Address - Country:US
Mailing Address - Phone:239-424-1687
Mailing Address - Fax:239-343-4186
Practice Address - Street 1:2441 SURFSIDE BLVD STE 200
Practice Address - Street 2:
Practice Address - City:CAPE CORAL
Practice Address - State:FL
Practice Address - Zip Code:33914-3861
Practice Address - Country:US
Practice Address - Phone:239-424-1687
Practice Address - Fax:239-343-4186
Is Sole Proprietor?:No
Enumeration Date:2012-07-07
Last Update Date:2022-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301101017207R00000X
FLME156758207RR0500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RR0500XAllopathic & Osteopathic PhysiciansInternal MedicineRheumatology
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL114202000Medicaid