Provider Demographics
NPI:1255441606
Name:CORSENTINO - MATSUMOTO, LISA (DO)
Entity type:Individual
Prefix:
First Name:LISA
Middle Name:
Last Name:CORSENTINO - MATSUMOTO
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12710 CARMEL COUNTRY RD
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92130-2153
Mailing Address - Country:US
Mailing Address - Phone:858-499-2708
Mailing Address - Fax:
Practice Address - Street 1:12710 CARMEL COUNTRY RD
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92130-2153
Practice Address - Country:US
Practice Address - Phone:858-499-2708
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-30
Last Update Date:2012-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA20A6906207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAH01895Medicare UPIN
CAW20A6906DMedicare ID - Type Unspecified