Provider Demographics
NPI:1891896163
Name:LAMB, KENNETH CECIL (MD)
Entity Type:Individual
Prefix:DR
First Name:KENNETH
Middle Name:CECIL
Last Name:LAMB
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:122 CALISTOGA RD # 399
Mailing Address - Street 2:
Mailing Address - City:SANTA ROSA
Mailing Address - State:CA
Mailing Address - Zip Code:95409-3702
Mailing Address - Country:US
Mailing Address - Phone:707-525-3777
Mailing Address - Fax:707-538-8307
Practice Address - Street 1:122 CALISTOGA RD # 399
Practice Address - Street 2:
Practice Address - City:SANTA ROSA
Practice Address - State:CA
Practice Address - Zip Code:95409-3702
Practice Address - Country:US
Practice Address - Phone:707-525-3777
Practice Address - Fax:707-538-8307
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-26
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG27121207RC0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0200XAllopathic & Osteopathic PhysiciansInternal MedicineCritical Care Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G271210Medicaid
CAA43241Medicare UPIN
CA00G271210Medicare ID - Type UnspecifiedMEDICARE ID