Provider Demographics
NPI:1649362831
Name:MATSUNAGA, JON STACEY (MD)
Entity type:Individual
Prefix:DR
First Name:JON
Middle Name:STACEY
Last Name:MATSUNAGA
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2001 SANTA MONICA BLVD
Mailing Address - Street 2:#970-W
Mailing Address - City:SANTA MONICA
Mailing Address - State:CA
Mailing Address - Zip Code:90404-2102
Mailing Address - Country:US
Mailing Address - Phone:310-829-7878
Mailing Address - Fax:310-453-5586
Practice Address - Street 1:2001 SANTA MONICA BLVD STE 970W
Practice Address - Street 2:
Practice Address - City:SANTA MONICA
Practice Address - State:CA
Practice Address - Zip Code:90404-2199
Practice Address - Country:US
Practice Address - Phone:310-829-7878
Practice Address - Fax:310-453-5586
Is Sole Proprietor?:No
Enumeration Date:2006-09-28
Last Update Date:2021-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG50159174400000X, 207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
No174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAA92954Medicare UPIN