Healthcare Provider Details

I. General information

NPI: 1821211186
Provider Name (Legal Business Name): KEVIN T MARMOLEJO M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/11/2007
Last Update Date: 12/15/2021
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4441 E KINGS CANYON RD
FRESNO CA
93702-3604
US

IV. Provider business mailing address

PO BOX 11800
FRESNO CA
93775-1800
US

V. Phone/Fax

Practice location:
  • Phone: 559-453-6599
  • Fax: 559-453-8234
Mailing address:
  • Phone: 559-453-6599
  • Fax: 559-453-8234

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0015X
TaxonomyPsychosomatic Medicine Physician
License NumberA89294
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: