Healthcare Provider Details

I. General information

NPI: 1982709028
Provider Name (Legal Business Name): KEVIN M MOYNIHAN MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/13/2006
Last Update Date: 11/09/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1901 W KETTLEMAN LN SUITE 200
LODI CA
95242-4337
US

IV. Provider business mailing address

2545 E BIDWELL ST STE 110
FOLSOM CA
95630-6443
US

V. Phone/Fax

Practice location:
  • Phone: 209-334-8540
  • Fax: 209-368-2885
Mailing address:
  • Phone: 916-983-8868
  • Fax: 916-983-8891

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberG78161
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: