Provider Demographics
NPI:1770656357
Name:MATSUNO, LORI LYNN (OD)
Entity Type:Individual
Prefix:DR
First Name:LORI
Middle Name:LYNN
Last Name:MATSUNO
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 1:210 S GRAND AVE
Mailing Address - Street 2:SUITE 115
Mailing Address - City:GLENDORA
Mailing Address - State:CA
Mailing Address - Zip Code:91741-4263
Mailing Address - Country:US
Mailing Address - Phone:626-857-0234
Mailing Address - Fax:626-857-0857
Practice Address - Street 1:210 S GRAND AVE
Practice Address - Street 2:SUITE 115
Practice Address - City:GLENDORA
Practice Address - State:CA
Practice Address - Zip Code:91741-4263
Practice Address - Country:US
Practice Address - Phone:626-857-0234
Practice Address - Fax:626-857-0857
Is Sole Proprietor?:No
Enumeration Date:2006-11-15
Last Update Date:2009-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAOPT8800T152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CASD0088000Medicaid
CAOP8800Medicare ID - Type UnspecifiedMEDICARE
CAU67238Medicare UPIN
CAOP8800Medicare PIN
CAAX675ZMedicare PIN