Provider Demographics
NPI:1124413596
Name:OMWANGHE, KIMBERLI (MD)
Entity Type:Individual
Prefix:
First Name:KIMBERLI
Middle Name:
Last Name:OMWANGHE
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 1:221 REGENCY PKWY STE 121
Mailing Address - Street 2:
Mailing Address - City:MANSFIELD
Mailing Address - State:TX
Mailing Address - Zip Code:76063-5379
Mailing Address - Country:US
Mailing Address - Phone:817-477-5884
Mailing Address - Fax:817-453-8091
Practice Address - Street 1:221 REGENCY PKWY STE 121
Practice Address - Street 2:
Practice Address - City:MANSFIELD
Practice Address - State:TX
Practice Address - Zip Code:76063
Practice Address - Country:US
Practice Address - Phone:817-477-5884
Practice Address - Fax:817-453-8091
Is Sole Proprietor?:No
Enumeration Date:2015-04-02
Last Update Date:2018-09-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARE-10387207P00000X
390200000X
TXR8448207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program