Healthcare Provider Details

I. General information

NPI: 1093249864
Provider Name (Legal Business Name): MYLES JULIAN KETCHUM M.D., PH.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/18/2017
Last Update Date: 05/27/2025
Certification Date: 05/27/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2360 MENDOCINO AVE
SANTA ROSA CA
95403-3153
US

IV. Provider business mailing address

PO BOX 276950
SACRAMENTO CA
95827-6950
US

V. Phone/Fax

Practice location:
  • Phone: 707-573-5250
  • Fax: 707-573-5458
Mailing address:
  • Phone: 707-573-5250
  • Fax: 707-573-5458

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2083A0300X
TaxonomyAddiction Medicine (Preventive Medicine) Physician
License Number61-25999
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code207QA0401X
TaxonomyAddiction Medicine (Family Medicine) Physician
License Number1211497
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: