Provider Demographics
NPI:1093249864
Name:KETCHUM, MYLES JULIAN (MD, PHD)
Entity type:Individual
Prefix:
First Name:MYLES
Middle Name:JULIAN
Last Name:KETCHUM
Suffix:
Gender:M
Credentials:MD, PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 276950
Mailing Address - Street 2:
Mailing Address - City:SACRAMENTO
Mailing Address - State:CA
Mailing Address - Zip Code:95827-6950
Mailing Address - Country:US
Mailing Address - Phone:707-573-5250
Mailing Address - Fax:707-573-5458
Practice Address - Street 1:2360 MENDOCINO AVE
Practice Address - Street 2:
Practice Address - City:SANTA ROSA
Practice Address - State:CA
Practice Address - Zip Code:95403-3153
Practice Address - Country:US
Practice Address - Phone:707-573-5250
Practice Address - Fax:707-573-5458
Is Sole Proprietor?:Yes
Enumeration Date:2017-04-18
Last Update Date:2025-05-27
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
CA61-259992083A0300X
CA1211497207QA0401X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207QA0401XAllopathic & Osteopathic PhysiciansFamily MedicineAddiction Medicine
No2083A0300XAllopathic & Osteopathic PhysiciansPreventive MedicineAddiction Medicine