Provider Demographics
NPI:1093757221
Name:KIMBALL, RICHARD (MD)
Entity Type:Individual
Prefix:DR
First Name:RICHARD
Middle Name:
Last Name:KIMBALL
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:PO BOX 1027
Mailing Address - Street 2:
Mailing Address - City:JEFFERSON CITY
Mailing Address - State:MO
Mailing Address - Zip Code:65102-1027
Mailing Address - Country:US
Mailing Address - Phone:573-761-7000
Mailing Address - Fax:573-761-6947
Practice Address - Street 1:2265 BAGNELL DAM BLVD
Practice Address - Street 2:STE 103
Practice Address - City:LAKE OZARK
Practice Address - State:MO
Practice Address - Zip Code:65049
Practice Address - Country:US
Practice Address - Phone:573-365-6800
Practice Address - Fax:573-365-6011
Is Sole Proprietor?:No
Enumeration Date:2006-06-12
Last Update Date:2013-01-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO115148207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO203852215Medicaid
MO203852215Medicaid