Healthcare Provider Details

I. General information

NPI: 1104829431
Provider Name (Legal Business Name): KEVIN IRVING STROH DPM
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/31/2005
Last Update Date: 05/19/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1300 W LODI AVE STE W
LODI CA
95242-3037
US

IV. Provider business mailing address

1300 W LODI AVE STE W
LODI CA
95242-3037
US

V. Phone/Fax

Practice location:
  • Phone: 209-334-6664
  • Fax: 209-334-2379
Mailing address:
  • Phone: 209-334-6664
  • Fax: 209-334-2379

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code213ES0103X
TaxonomyFoot & Ankle Surgery Podiatrist
License NumberE34670
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code213E00000X
TaxonomyPodiatrist
License NumberE3467
License Number StateCA
# 3
Primary TaxonomyN
Taxonomy Code213ER0200X
TaxonomyRadiology Podiatrist
License NumberE3467
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: