Provider Demographics
NPI:1770672123
Name:MOTTA, KIMBERLY LYN (MD)
Entity Type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:LYN
Last Name:MOTTA
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:KIMBERLY
Other - Middle Name:LYN
Other - Last Name:MOTTA
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:17360 BROOKHURST STREEET
Mailing Address - Street 2:ATTN: MCMF - CREDENTIALING DEPT.
Mailing Address - City:FOUNTAIN VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:92708-3720
Mailing Address - Country:US
Mailing Address - Phone:657-241-3592
Mailing Address - Fax:
Practice Address - Street 1:17360 BROOKHURST ST
Practice Address - Street 2:
Practice Address - City:FOUNTAIN VALLEY
Practice Address - State:CA
Practice Address - Zip Code:92708-3720
Practice Address - Country:US
Practice Address - Phone:714-665-1797
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-12
Last Update Date:2016-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA65953207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
1912919804OtherTYPE 2 - GROUP NPI
CACB206903Medicare PIN
CACK194XMedicare PIN
CAH24425Medicare UPIN
CAWA65953CMedicare ID - Type Unspecified