Provider Demographics
NPI:1114904398
Name:KIMBALL, JAY W (MD)
Entity Type:Individual
Prefix:DR
First Name:JAY
Middle Name:W
Last Name:KIMBALL
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
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Other - Credentials:
Mailing Address - Street 1:9411 N OAK TRFY
Mailing Address - Street 2:# LL1
Mailing Address - City:KANSAS CITY
Mailing Address - State:MO
Mailing Address - Zip Code:64155-2233
Mailing Address - Country:US
Mailing Address - Phone:816-436-7072
Mailing Address - Fax:816-436-2743
Practice Address - Street 1:6450 N CHATHAM AVE
Practice Address - Street 2:
Practice Address - City:KANSAS CITY
Practice Address - State:MO
Practice Address - Zip Code:64151
Practice Address - Country:US
Practice Address - Phone:816-741-5542
Practice Address - Fax:816-746-4262
Is Sole Proprietor?:No
Enumeration Date:2005-12-28
Last Update Date:2013-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MOR6A86207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO0004717Medicare ID - Type Unspecified
MOC50427Medicare UPIN