Provider Demographics
NPI:1629622543
Name:MATSUO, ALYSSA AKIMI (OD)
Entity Type:Individual
Prefix:
First Name:ALYSSA
Middle Name:AKIMI
Last Name:MATSUO
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 1:384 SPINNAKER WAY
Mailing Address - Street 2:
Mailing Address - City:SACRAMENTO
Mailing Address - State:CA
Mailing Address - Zip Code:95831-3235
Mailing Address - Country:US
Mailing Address - Phone:916-799-2583
Mailing Address - Fax:
Practice Address - Street 1:9221 SIERRA COLLEGE BLVD STE 130
Practice Address - Street 2:
Practice Address - City:ROSEVILLE
Practice Address - State:CA
Practice Address - Zip Code:95661-5919
Practice Address - Country:US
Practice Address - Phone:916-797-6747
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-07-29
Last Update Date:2019-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA34284TLG152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist