Provider Demographics
NPI:1073396065
Name:KIMMEL, JUSTIN
Entity Type:Individual
Prefix:
First Name:JUSTIN
Middle Name:
Last Name:KIMMEL
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:335588 E 750 RD
Mailing Address - Street 2:
Mailing Address - City:PERKINS
Mailing Address - State:OK
Mailing Address - Zip Code:74059-3268
Mailing Address - Country:US
Mailing Address - Phone:405-547-4363
Mailing Address - Fax:
Practice Address - Street 1:509 E HIGHWAY 33
Practice Address - Street 2:
Practice Address - City:PERKINS
Practice Address - State:OK
Practice Address - Zip Code:74059-4129
Practice Address - Country:US
Practice Address - Phone:405-547-4363
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-08-15
Last Update Date:2023-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175T00000XOther Service ProvidersPeer Specialist