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General NPI Number Information
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NPI Number | 1093249864
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Entity Type | Individual
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Provider Name | MYLES JULIAN KETCHUM M.D., PH.D.
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Gender | Male
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Dates
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Enumeration Date | 04/18/2017
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Last Update Date | 05/27/2025
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Provider Practice Location Address
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Address Line | 2360 MENDOCINO AVE
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City | SANTA ROSA
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State | CA
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Zip | 95403-3153
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Country | US
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Telephone | 707-573-5250
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Fax | 707-573-5458
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Provider Business Mailing Address
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Address Line | PO BOX 276950
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City | SACRAMENTO
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State | CA
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Zip | 95827-6950
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Country | US
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Telephone | 707-573-5250
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Fax | 707-573-5458
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 2083A0300X
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Taxonomy Name | Addiction Medicine (Preventive Medicine) Physician
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License Number | 61-25999
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License Number State | CA
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Taxonomy #2
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Taxonomy Code | 207QA0401X
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Taxonomy Name | Addiction Medicine (Family Medicine) Physician
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License Number | 1211497
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License Number State | CA
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