Provider Demographics
NPI:1518069848
Name:MATSUMOTO, EDEANE S (MD)
Entity Type:Individual
Prefix:DR
First Name:EDEANE
Middle Name:S
Last Name:MATSUMOTO
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
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Mailing Address - Street 1:2101 FOREST AVE
Mailing Address - Street 2:SUITE 227
Mailing Address - City:SAN JOSE
Mailing Address - State:CA
Mailing Address - Zip Code:95128-1448
Mailing Address - Country:US
Mailing Address - Phone:408-289-5320
Mailing Address - Fax:408-289-5323
Practice Address - Street 1:2101 FOREST AVE
Practice Address - Street 2:SUITE 227
Practice Address - City:SAN JOSE
Practice Address - State:CA
Practice Address - Zip Code:95128-1448
Practice Address - Country:US
Practice Address - Phone:408-289-5320
Practice Address - Fax:408-289-5323
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-05
Last Update Date:2010-07-13
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
CAG67911207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA522354601OtherTAX ID
CAG67911OtherSTATE LICENSE
CAG67911OtherSTATE LICENSE