Provider Demographics
NPI:1104829431
Name:STROH, KEVIN IRVING (DPM)
Entity Type:Individual
Prefix:
First Name:KEVIN
Middle Name:IRVING
Last Name:STROH
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1300 W LODI AVE
Mailing Address - Street 2:STE W
Mailing Address - City:LODI
Mailing Address - State:CA
Mailing Address - Zip Code:95242-3037
Mailing Address - Country:US
Mailing Address - Phone:209-334-6664
Mailing Address - Fax:209-334-2379
Practice Address - Street 1:1300 W LODI AVE
Practice Address - Street 2:STE W
Practice Address - City:LODI
Practice Address - State:CA
Practice Address - Zip Code:95242-3037
Practice Address - Country:US
Practice Address - Phone:209-334-6664
Practice Address - Fax:209-334-2379
Is Sole Proprietor?:No
Enumeration Date:2005-05-31
Last Update Date:2010-05-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAE34670213ES0103X
CAE3467213E00000X, 213ER0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
No213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery
No213ER0200XPodiatric Medicine & Surgery Service ProvidersPodiatristRadiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA000E34670Medicaid
CAT90634Medicare UPIN
CA000E34670Medicaid