Provider Demographics
NPI:1174510127
Name:GATZIMOS, KIMBERLY ROSE (MD)
Entity Type:Individual
Prefix:DR
First Name:KIMBERLY
Middle Name:ROSE
Last Name:GATZIMOS
Suffix:
Gender:F
Credentials:MD
Other - Prefix:DR
Other - First Name:KIMBERLY
Other - Middle Name:ROSE
Other - Last Name:JOHNSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:2705 N LEBANON ST STE 305
Mailing Address - Street 2:
Mailing Address - City:LEBANON
Mailing Address - State:IN
Mailing Address - Zip Code:46052-8622
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1650 W OAK ST STE 203
Practice Address - Street 2:
Practice Address - City:ZIONSVILLE
Practice Address - State:IN
Practice Address - Zip Code:46077-3836
Practice Address - Country:US
Practice Address - Phone:317-873-1200
Practice Address - Fax:317-873-1209
Is Sole Proprietor?:Yes
Enumeration Date:2005-10-04
Last Update Date:2021-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01037050207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200134930Medicaid
ING51949Medicare UPIN
IN183270AMedicare ID - Type Unspecified