Provider Demographics
NPI:1164482501
Name:EDGMON, KIMBERLY (MD)
Entity Type:Individual
Prefix:DR
First Name:KIMBERLY
Middle Name:
Last Name:EDGMON
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 1:2820 N KELLY AVE
Mailing Address - Street 2:SUITE 200
Mailing Address - City:EDMOND
Mailing Address - State:OK
Mailing Address - Zip Code:73003-3007
Mailing Address - Country:US
Mailing Address - Phone:405-726-8000
Mailing Address - Fax:405-726-8101
Practice Address - Street 1:2820 N KELLY AVE
Practice Address - Street 2:SUITE 200
Practice Address - City:EDMOND
Practice Address - State:OK
Practice Address - Zip Code:73003-3007
Practice Address - Country:US
Practice Address - Phone:405-726-8000
Practice Address - Fax:405-726-8101
Is Sole Proprietor?:No
Enumeration Date:2006-03-27
Last Update Date:2016-05-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK24371208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK33536OtherOBNDD
OK24371OtherLICENSE
OK200057440AMedicaid
OK24371OtherLICENSE