Provider Demographics
NPI:1962455907
Name:JERRY MATSUMURA MD, INC. A PROFESSIONAL CORPORATION
Entity Type:Organization
Organization Name:JERRY MATSUMURA MD, INC. A PROFESSIONAL CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:JERRY
Authorized Official - Middle Name:S
Authorized Official - Last Name:MATSUMURA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:801-993-9534
Mailing Address - Street 1:18124 WEDGE PKWY STE 232
Mailing Address - Street 2:
Mailing Address - City:RENO
Mailing Address - State:NV
Mailing Address - Zip Code:89511-8134
Mailing Address - Country:US
Mailing Address - Phone:801-993-9534
Mailing Address - Fax:775-853-2728
Practice Address - Street 1:18124 WEDGE PKWY STE 232
Practice Address - Street 2:
Practice Address - City:RENO
Practice Address - State:NV
Practice Address - Zip Code:89511-8134
Practice Address - Country:US
Practice Address - Phone:801-993-9534
Practice Address - Fax:775-853-2728
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-19
Last Update Date:2008-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV7899207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NVV100540Medicare PIN