Provider Demographics
NPI:1093765521
Name:EUBANKS, KIM PATRICE (MD)
Entity Type:Individual
Prefix:DR
First Name:KIM
Middle Name:PATRICE
Last Name:EUBANKS
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:541 10TH ST NW # 231
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30318-5713
Mailing Address - Country:US
Mailing Address - Phone:347-262-3054
Mailing Address - Fax:
Practice Address - Street 1:465 WINN WAY STE 231
Practice Address - Street 2:
Practice Address - City:DECATUR
Practice Address - State:GA
Practice Address - Zip Code:30030-1723
Practice Address - Country:US
Practice Address - Phone:347-262-3054
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL26227207Q00000X
GA055484207Q00000X
LA199994207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
I24630Medicare UPIN