Healthcare Provider Details

I. General information

NPI: 1770672123
Provider Name (Legal Business Name): KIMBERLY LYN MOTTA M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: KIMBERLY LYN MOTTA M.D.

II. Dates (important events)

Enumeration Date: 10/12/2006
Last Update Date: 05/20/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

17360 BROOKHURST ST
FOUNTAIN VALLEY CA
92708-3720
US

IV. Provider business mailing address

17360 BROOKHURST STREEET ATTN: MCMF - CREDENTIALING DEPT.
FOUNTAIN VALLEY CA
92708-3720
US

V. Phone/Fax

Practice location:
  • Phone: 714-665-1797
  • Fax:
Mailing address:
  • Phone: 657-241-3592
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberA65953
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: