Provider Demographics
NPI:1942213558
Name:MATSUMOTO, MAVIS N (MD)
Entity Type:Individual
Prefix:DR
First Name:MAVIS
Middle Name:N
Last Name:MATSUMOTO
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 530656
Mailing Address - Street 2:
Mailing Address - City:HENDERSON
Mailing Address - State:NV
Mailing Address - Zip Code:89053-0656
Mailing Address - Country:US
Mailing Address - Phone:702-992-4050
Mailing Address - Fax:702-992-4052
Practice Address - Street 1:2780 W HORIZON RIDGE PKWY
Practice Address - Street 2:SUITE 30
Practice Address - City:HENDERSON
Practice Address - State:NV
Practice Address - Zip Code:89052-3995
Practice Address - Country:US
Practice Address - Phone:702-992-4050
Practice Address - Fax:702-992-4052
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-14
Last Update Date:2016-03-22
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
NV7825207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV2019816Medicaid
NV2019816Medicaid
NVV35930Medicare PIN