Provider Demographics
NPI:1932142072
Name:MATSUMOTO, BRYAN M (MD)
Entity Type:Individual
Prefix:DR
First Name:BRYAN
Middle Name:M
Last Name:MATSUMOTO
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 1:98-1079 MOANALUA ROAD
Mailing Address - Street 2:SUITE 500
Mailing Address - City:AIEA
Mailing Address - State:HI
Mailing Address - Zip Code:96701-4794
Mailing Address - Country:US
Mailing Address - Phone:808-488-0990
Mailing Address - Fax:
Practice Address - Street 1:98-1079 MOANALUA ROAD
Practice Address - Street 2:SUITE 500
Practice Address - City:AIEA
Practice Address - State:HI
Practice Address - Zip Code:96701-4794
Practice Address - Country:US
Practice Address - Phone:808-488-0990
Practice Address - Fax:808-486-4696
Is Sole Proprietor?:No
Enumeration Date:2006-06-14
Last Update Date:2012-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
HIMD-4301207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
HI01018501Medicaid
HI0000BDJPLMedicare ID - Type Unspecified
HI01018501Medicaid