Provider Demographics
NPI:1366574360
Name:MATSUOKA, STANLEY M (OD)
Entity type:Individual
Prefix:DR
First Name:STANLEY
Middle Name:M
Last Name:MATSUOKA
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2049 BREA MALL
Mailing Address - Street 2:
Mailing Address - City:BREA
Mailing Address - State:CA
Mailing Address - Zip Code:92821-5756
Mailing Address - Country:US
Mailing Address - Phone:714-990-9311
Mailing Address - Fax:
Practice Address - Street 1:2049 BREA MALL
Practice Address - Street 2:
Practice Address - City:BREA
Practice Address - State:CA
Practice Address - Zip Code:92821-5756
Practice Address - Country:US
Practice Address - Phone:714-990-9311
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA5738T152WC0802X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152WC0802XEye and Vision Services ProvidersOptometristCorneal and Contact Management
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAU85215Medicare UPIN