Provider Demographics
NPI:1558452441
Name:MATSUMOTO, ELLEN REIKO (OD)
Entity Type:Individual
Prefix:
First Name:ELLEN
Middle Name:REIKO
Last Name:MATSUMOTO
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6430 W SUNSET BLVD
Mailing Address - Street 2:SUITE 600
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90028-7901
Mailing Address - Country:US
Mailing Address - Phone:323-361-2337
Mailing Address - Fax:323-361-8491
Practice Address - Street 1:4650 W SUNSET BLVD
Practice Address - Street 2:MS# 88
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90027-6062
Practice Address - Country:US
Practice Address - Phone:323-361-2344
Practice Address - Fax:323-666-6283
Is Sole Proprietor?:No
Enumeration Date:2006-09-27
Last Update Date:2008-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAOPT6291207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CASD0062910Medicaid
CAEMY4363Medicare ID - Type Unspecified
CAU11244Medicare UPIN