Provider Demographics
NPI:1720044761
Name:COX, KIANA LEE NICOLE (MD)
Entity Type:Individual
Prefix:
First Name:KIANA LEE
Middle Name:NICOLE
Last Name:COX
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:600 COFFEE RD
Mailing Address - Street 2:
Mailing Address - City:MODESTO
Mailing Address - State:CA
Mailing Address - Zip Code:95355-4201
Mailing Address - Country:US
Mailing Address - Phone:209-524-1211
Mailing Address - Fax:
Practice Address - Street 1:1300 W LODI AVE
Practice Address - Street 2:SUITE P
Practice Address - City:LODI
Practice Address - State:CA
Practice Address - Zip Code:95242-3000
Practice Address - Country:US
Practice Address - Phone:209-366-1990
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-04-26
Last Update Date:2010-05-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA69911207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A699110Medicaid
CAH40684Medicare UPIN
CA00A699110Medicaid