Basic Information
| Provider Information | |||||||||
| NPI: | 1720223175 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MATSUURA | ||||||||
| FirstName: | MICHAEL | ||||||||
| MiddleName: | JOHN | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 8716 POLISHED PEBBLE WAY | ||||||||
| Address2: | |||||||||
| City: | LAUREL | ||||||||
| State: | MD | ||||||||
| PostalCode: | 207235909 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4103286704 | ||||||||
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| Practice Location | |||||||||
| Address1: | 22 S GREENE ST | ||||||||
| Address2: | |||||||||
| City: | BALTIMORE | ||||||||
| State: | MD | ||||||||
| PostalCode: | 212011544 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4103286704 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 12/12/2008 | ||||||||
| LastUpdateDate: | 02/24/2012 | ||||||||
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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 | 208D00000X | MD-14431 | HI | N | Allopathic & Osteopathic Physicians | General Practice | 208600000X | D72797 | MD | Y | Allopathic & Osteopathic Physicians | Surgery |
ID Information
| ID | Type | State | Issuer | Description | 442253800 | 05 | MD | MEDICAID |