Basic Information
Provider Information | |||||||||
NPI: | 1770672123 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | MOTTA | ||||||||
FirstName: | KIMBERLY | ||||||||
MiddleName: | LYN | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | M.D. | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | MOTTA | ||||||||
OtherFirstName: | KIMBERLY | ||||||||
OtherMiddleName: | LYN | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: | M.D. | ||||||||
OtherLastNameType: | 2 | ||||||||
Mailing Information | |||||||||
Address1: | 17360 BROOKHURST STREEET | ||||||||
Address2: | ATTN: MCMF - CREDENTIALING DEPT. | ||||||||
City: | FOUNTAIN VALLEY | ||||||||
State: | CA | ||||||||
PostalCode: | 927083720 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6572413592 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 17360 BROOKHURST ST | ||||||||
Address2: |   | ||||||||
City: | FOUNTAIN VALLEY | ||||||||
State: | CA | ||||||||
PostalCode: | 927083720 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7146651797 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 10/12/2006 | ||||||||
LastUpdateDate: | 05/20/2016 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | A65953 | CA | Y |   | Allopathic & Osteopathic Physicians | Internal Medicine |   |
ID Information
ID | Type | State | Issuer | Description | 1912919804 | 01 |   | TYPE 2 - GROUP NPI | OTHER |