Basic Information
Provider Information | |||||||||
NPI: | 1730117573 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | MATSUMURA | ||||||||
FirstName: | BRITTANY | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | MD | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 10100 | ||||||||
Address2: |   | ||||||||
City: | DELTA | ||||||||
State: | CO | ||||||||
PostalCode: | 814160008 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9708742470 | ||||||||
FaxNumber: | 9708742849 | ||||||||
Practice Location | |||||||||
Address1: | 205 STAFFORD LN | ||||||||
Address2: |   | ||||||||
City: | DELTA | ||||||||
State: | CO | ||||||||
PostalCode: | 814162229 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9708742476 | ||||||||
FaxNumber: | 9708742849 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 06/29/2006 | ||||||||
LastUpdateDate: | 02/26/2008 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208100000X | 228955 | NY | N |   | Allopathic & Osteopathic Physicians | Physical Medicine & Rehabilitation |   | 208100000X | 44447 | CO | Y |   | Allopathic & Osteopathic Physicians | Physical Medicine & Rehabilitation |   | 208100000X | 6174926-1205 | UT | N |   | Allopathic & Osteopathic Physicians | Physical Medicine & Rehabilitation |   |
ID Information
ID | Type | State | Issuer | Description | 840428757042 | 01 |   | RMHP | OTHER | 87030268 | 05 | CO |   | MEDICAID | MA44447 | 01 |   | BCBS | OTHER |