Provider Demographics
NPI:1104205442
Name:KIMBAL, KYLE CLARK (MD, MS)
Entity Type:Individual
Prefix:
First Name:KYLE
Middle Name:CLARK
Last Name:KIMBAL
Suffix:
Gender:M
Credentials:MD, MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1220 SUNRISE PL
Mailing Address - Street 2:
Mailing Address - City:BOUNTIFUL
Mailing Address - State:UT
Mailing Address - Zip Code:84010-3212
Mailing Address - Country:US
Mailing Address - Phone:801-710-4222
Mailing Address - Fax:
Practice Address - Street 1:1380 E MEDICAL CENTER DR STE 4500
Practice Address - Street 2:
Practice Address - City:ST GEORGE
Practice Address - State:UT
Practice Address - Zip Code:84790-2123
Practice Address - Country:US
Practice Address - Phone:435-251-2501
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-05-19
Last Update Date:2023-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXBP100554443208600000X
UT12494828-1205208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery