Provider Demographics
NPI:1538111927
Name:MATSUURA, STACEY K (MD)
Entity Type:Individual
Prefix:
First Name:STACEY
Middle Name:K
Last Name:MATSUURA
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 1:21311 MADRONA AVE
Mailing Address - Street 2:SUITE 100-A
Mailing Address - City:TORRANCE
Mailing Address - State:CA
Mailing Address - Zip Code:90503-4352
Mailing Address - Country:US
Mailing Address - Phone:310-792-4400
Mailing Address - Fax:310-542-5805
Practice Address - Street 1:21311 MADRONA AVE
Practice Address - Street 2:SUITE 100-A
Practice Address - City:TORRANCE
Practice Address - State:CA
Practice Address - Zip Code:90503-5970
Practice Address - Country:US
Practice Address - Phone:310-792-4400
Practice Address - Fax:310-542-5805
Is Sole Proprietor?:No
Enumeration Date:2006-05-16
Last Update Date:2021-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG38258207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAWG38258HMedicare ID - Type UnspecifiedMEDICARE PPIN
A47414Medicare UPIN
CAWG38258FMedicare ID - Type UnspecifiedMEDICARE PPIN