Provider Demographics
NPI:1659454635
Name:KEITH T MATSUMOTO MD INC
Entity Type:Organization
Organization Name:KEITH T MATSUMOTO MD INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:KEITH
Authorized Official - Middle Name:TSUGIO
Authorized Official - Last Name:MATSUMOTO
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:808-949-0011
Mailing Address - Street 1:1319 PUNAHOU ST
Mailing Address - Street 2:SUITE 900
Mailing Address - City:HONOLULU
Mailing Address - State:HI
Mailing Address - Zip Code:96826-1032
Mailing Address - Country:US
Mailing Address - Phone:808-949-0011
Mailing Address - Fax:808-943-2536
Practice Address - Street 1:1319 PUNAHOU ST
Practice Address - Street 2:SUITE 900
Practice Address - City:HONOLULU
Practice Address - State:HI
Practice Address - Zip Code:96826-1032
Practice Address - Country:US
Practice Address - Phone:808-949-0011
Practice Address - Fax:808-943-2536
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-23
Last Update Date:2014-06-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
HI4464208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
00D0011215OtherHMSA QUEST
HI01076801Medicaid
194670OtherHMN
00D0011215OtherHMSA
MD446401OtherQUEENS HEALTH CARE
MD446401OtherQUEENS HEALTH CARE
HI01076801Medicaid
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