Provider Demographics
NPI:1972816007
Name:MATSUO, KIMBERLY
Entity Type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:
Last Name:MATSUO
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14 PENN PLZ
Mailing Address - Street 2:STE 408
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10122-0049
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:14 PENN PLZ
Practice Address - Street 2:STE 408
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10122-0049
Practice Address - Country:US
Practice Address - Phone:212-237-3012
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-07-19
Last Update Date:2016-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYTUV007592-1152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist