Provider Demographics
NPI:1427112028
Name:MATSUMOTO, SHAUN ROBERT (DC)
Entity type:Individual
Prefix:DR
First Name:SHAUN
Middle Name:ROBERT
Last Name:MATSUMOTO
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1171 N ALTA AVE
Mailing Address - Street 2:
Mailing Address - City:DINUBA
Mailing Address - State:CA
Mailing Address - Zip Code:93618
Mailing Address - Country:US
Mailing Address - Phone:559-315-5070
Mailing Address - Fax:559-315-5726
Practice Address - Street 1:1171 N ALTA AVE
Practice Address - Street 2:
Practice Address - City:DINUBA
Practice Address - State:CA
Practice Address - Zip Code:93618
Practice Address - Country:US
Practice Address - Phone:559-315-5070
Practice Address - Fax:559-315-5726
Is Sole Proprietor?:No
Enumeration Date:2006-12-20
Last Update Date:2024-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CADC30341111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAMMM00104MOtherMEDICARE GROUP #
CADC0303410Medicare PIN