Provider Demographics
NPI:1689036816
Name:MATSUMOTO, IVAN
Entity Type:Individual
Prefix:
First Name:IVAN
Middle Name:
Last Name:MATSUMOTO
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:444 W 54TH ST
Mailing Address - Street 2:APT # 12
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10019-7605
Mailing Address - Country:US
Mailing Address - Phone:808-226-3431
Mailing Address - Fax:
Practice Address - Street 1:444 W 54TH ST
Practice Address - Street 2:APT # 12
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10019-7605
Practice Address - Country:US
Practice Address - Phone:808-226-3431
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-03-26
Last Update Date:2016-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY22MA1267932174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist