Provider Demographics
NPI:1144419839
Name:G. KIMBLE JETT, MD, PA
Entity Type:Organization
Organization Name:G. KIMBLE JETT, MD, PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT, SURGEON
Authorized Official - Prefix:DR
Authorized Official - First Name:GARY
Authorized Official - Middle Name:KIMBLE
Authorized Official - Last Name:JETT
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:972-731-7506
Mailing Address - Street 1:5575 WARREN PKWY STE 306
Mailing Address - Street 2:
Mailing Address - City:FRISCO
Mailing Address - State:TX
Mailing Address - Zip Code:75034-4097
Mailing Address - Country:US
Mailing Address - Phone:972-731-7506
Mailing Address - Fax:972-731-7512
Practice Address - Street 1:5575 WARREN PKWY STE 306
Practice Address - Street 2:
Practice Address - City:FRISCO
Practice Address - State:TX
Practice Address - Zip Code:75034-4097
Practice Address - Country:US
Practice Address - Phone:972-731-7506
Practice Address - Fax:972-731-7512
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-10-18
Last Update Date:2011-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXF1681174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX00729WOtherMEDICARE
TX0979981Medicaid
TXB73054Medicare UPIN