Provider Demographics
NPI:1053330803
Name:WIMBERLY, KELLY L (MD)
Entity Type:Individual
Prefix:DR
First Name:KELLY
Middle Name:L
Last Name:WIMBERLY
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:17101 PRESTON RD
Mailing Address - Street 2:SUITE 200
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75248-1331
Mailing Address - Country:US
Mailing Address - Phone:972-239-4441
Mailing Address - Fax:972-239-1597
Practice Address - Street 1:17101 PRESTON RD
Practice Address - Street 2:SUITE 200
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75248-1331
Practice Address - Country:US
Practice Address - Phone:972-239-4441
Practice Address - Fax:972-239-1597
Is Sole Proprietor?:No
Enumeration Date:2006-07-19
Last Update Date:2011-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXJ3002207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXP00474586OtherMEDICARE RR PIN
TXDH1426OtherMEDICARE RR GROUP NUMBER
TX00407XMedicare ID - Type Unspecified
TX8C6319Medicare ID - Type Unspecified
TXP00474586OtherMEDICARE RR PIN