Provider Demographics
NPI:1255463071
Name:GARY MATSUMURA MD A PROFESSIONAL MEDICAL CORPORATION
Entity type:Organization
Organization Name:GARY MATSUMURA MD A PROFESSIONAL MEDICAL CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:GARY
Authorized Official - Middle Name:ARTHUR
Authorized Official - Last Name:MATSUMURA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:707-695-8000
Mailing Address - Street 1:PO BOX 1862
Mailing Address - Street 2:
Mailing Address - City:SUISUN CITY
Mailing Address - State:CA
Mailing Address - Zip Code:94585
Mailing Address - Country:US
Mailing Address - Phone:707-695-8000
Mailing Address - Fax:707-864-3506
Practice Address - Street 1:1817 ROCKVILLE ROAD
Practice Address - Street 2:
Practice Address - City:FAIRFIED
Practice Address - State:CA
Practice Address - Zip Code:94534-1412
Practice Address - Country:US
Practice Address - Phone:707-695-8000
Practice Address - Fax:707-864-3506
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-09
Last Update Date:2007-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAGR0103180Medicaid
CAZZZ05389ZMedicare PIN