Provider Demographics
NPI:1932497229
Name:MAVIS N MATSUMOTO, MD, LLC
Entity Type:Organization
Organization Name:MAVIS N MATSUMOTO, MD, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:MAVIS
Authorized Official - Middle Name:N
Authorized Official - Last Name:MATSUMOTO
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:702-992-4050
Mailing Address - Street 1:870 SEVEN HILLS DR
Mailing Address - Street 2:SUITE 102
Mailing Address - City:HENDERSON
Mailing Address - State:NV
Mailing Address - Zip Code:89052-4377
Mailing Address - Country:US
Mailing Address - Phone:702-992-4050
Mailing Address - Fax:702-992-4052
Practice Address - Street 1:870 SEVEN HILLS DR
Practice Address - Street 2:SUITE 102
Practice Address - City:HENDERSON
Practice Address - State:NV
Practice Address - Zip Code:89052-4377
Practice Address - Country:US
Practice Address - Phone:702-992-4050
Practice Address - Fax:702-992-4052
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-07-20
Last Update Date:2012-04-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV7825261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
NVG31004Medicare UPIN