Basic Information
| Provider Information | |||||||||
| NPI: | 1053600429 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MATSUO | ||||||||
| FirstName: | KEN | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 1090 | ||||||||
| Address2: | |||||||||
| City: | WINDSOR | ||||||||
| State: | CT | ||||||||
| PostalCode: | 060956190 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8009257270 | ||||||||
| FaxNumber: | 8883311015 | ||||||||
| Practice Location | |||||||||
| Address1: | 56 FRANKLIN ST | ||||||||
| Address2: | |||||||||
| City: | WATERBURY | ||||||||
| State: | CT | ||||||||
| PostalCode: | 067061253 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2037098820 | ||||||||
| FaxNumber: | 2037093679 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/06/2011 | ||||||||
| LastUpdateDate: | 08/18/2014 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 390200000X | N | Student, Health Care | Student in an Organized Health Care Education/Training Program | 208M00000X | 53316 | CT | N | Allopathic & Osteopathic Physicians | Hospitalist | 207R00000X | 53316 | CT | Y | Allopathic & Osteopathic Physicians | Internal Medicine |
No ID Information.