Provider Demographics
NPI:1619907490
Name:MATSUMURA, KYLE SHIGERU (MD)
Entity Type:Individual
Prefix:DR
First Name:KYLE
Middle Name:SHIGERU
Last Name:MATSUMURA
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 1:6750 S HIGHLAND DRIVE
Mailing Address - Street 2:STE 100
Mailing Address - City:COTTONWOOD HEIGHTS
Mailing Address - State:UT
Mailing Address - Zip Code:84121
Mailing Address - Country:US
Mailing Address - Phone:801-685-7246
Mailing Address - Fax:801-747-5487
Practice Address - Street 1:6750 S HIGHLAND DRIVE
Practice Address - Street 2:STE 100
Practice Address - City:COTTONWOOD HEIGHTS
Practice Address - State:UT
Practice Address - Zip Code:84121
Practice Address - Country:US
Practice Address - Phone:801-685-7246
Practice Address - Fax:801-747-5487
Is Sole Proprietor?:No
Enumeration Date:2006-07-04
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT951306801205208VP0014X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208VP0014XAllopathic & Osteopathic PhysiciansPain MedicineInterventional Pain Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
UTD5367Medicaid
UTG79891OtherCAL MEDICAL LICENSE #
UT951306801205OtherUTAH MEDICAL LICENSE #
UTBM5218652OtherDEA NUMBER
UTG46186Medicare UPIN
UTD5367Medicaid