Provider Demographics
NPI:1083804322
Name:YEATES, KIMBERLY A (OD)
Entity Type:Individual
Prefix:MISS
First Name:KIMBERLY
Middle Name:A
Last Name:YEATES
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:834 HIGHWAY 12 W # 109
Mailing Address - Street 2:
Mailing Address - City:STARKVILLE
Mailing Address - State:MS
Mailing Address - Zip Code:39759-3582
Mailing Address - Country:US
Mailing Address - Phone:601-917-0667
Mailing Address - Fax:
Practice Address - Street 1:1913 HIGHWAY 45 N
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:MS
Practice Address - Zip Code:39705-1950
Practice Address - Country:US
Practice Address - Phone:601-917-0667
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-08-01
Last Update Date:2021-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS782152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL51593508OtherBLUE CROSS - BUTLER LOCATION
AL104290Medicaid
MSP00444208OtherRAILROAD MEDICARE
MS$$$$$$$$$OtherBLUE CROSS
AL009912502Medicaid
AL51593510OtherBLUE CROSS - LIVINGSTON LOCATION
AL104442Medicaid
MS09172334Medicaid
MS73104815OtherBLUE CROSS BLUE SHIELD OF ALABAMA
MSP00444208OtherRAILROAD MEDICARE
AL104290Medicaid
AL104442Medicaid