Provider Demographics
NPI:1679551204
Name:MATSUDA, GORDON T (MD)
Entity Type:Individual
Prefix:DR
First Name:GORDON
Middle Name:T
Last Name:MATSUDA
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 1:3434 47TH ST
Mailing Address - Street 2:SUITE 101
Mailing Address - City:BOULDER
Mailing Address - State:CO
Mailing Address - Zip Code:80301-1880
Mailing Address - Country:US
Mailing Address - Phone:303-444-0840
Mailing Address - Fax:303-444-0838
Practice Address - Street 1:3434 47TH ST
Practice Address - Street 2:SUITE 101
Practice Address - City:BOULDER
Practice Address - State:CO
Practice Address - Zip Code:80301-1880
Practice Address - Country:US
Practice Address - Phone:303-444-0840
Practice Address - Fax:303-444-0838
Is Sole Proprietor?:No
Enumeration Date:2006-01-04
Last Update Date:2009-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO20793208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO29504074Medicaid
COD36384Medicare UPIN
CO29504074Medicaid
CO803629Medicare ID - Type Unspecified