Provider Demographics
NPI:1144212689
Name:STUTZMAN, KIMBERLY KAHLER (MD)
Entity Type:Individual
Prefix:DR
First Name:KIMBERLY
Middle Name:KAHLER
Last Name:STUTZMAN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:DR
Other - First Name:KIMBERLY
Other - Middle Name:RENEE
Other - Last Name:KAHLER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:777 N RAYMOND ST
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83704-9251
Mailing Address - Country:US
Mailing Address - Phone:208-367-6042
Mailing Address - Fax:208-322-7018
Practice Address - Street 1:777 N RAYMOND ST
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83704-9251
Practice Address - Country:US
Practice Address - Phone:208-367-6042
Practice Address - Fax:208-322-7018
Is Sole Proprietor?:No
Enumeration Date:2005-08-19
Last Update Date:2009-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD0031115207Q00000X
ORMD19694207Q00000X
IDM9972207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID805823200Medicaid
WA8159519Medicaid
ID11000402Medicare PIN
ID1100040Medicare PIN
WA8159519Medicaid
WA000680911Medicare ID - Type Unspecified
ID11000401Medicare PIN