Provider Demographics
NPI:1205864204
Name:BROCKENBROUGH, KIMBERLY BROWN (MD)
Entity Type:Individual
Prefix:DR
First Name:KIMBERLY
Middle Name:BROWN
Last Name:BROCKENBROUGH
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 1:19020 33RD AVE W
Mailing Address - Street 2:SUITE 210
Mailing Address - City:LYNNWOOD
Mailing Address - State:WA
Mailing Address - Zip Code:98036-4746
Mailing Address - Country:US
Mailing Address - Phone:425-563-1500
Mailing Address - Fax:425-563-1374
Practice Address - Street 1:19020 33RD AVE W
Practice Address - Street 2:SUITE 210
Practice Address - City:LYNNWOOD
Practice Address - State:WA
Practice Address - Zip Code:98036-4746
Practice Address - Country:US
Practice Address - Phone:425-563-1500
Practice Address - Fax:425-563-1374
Is Sole Proprietor?:No
Enumeration Date:2006-06-29
Last Update Date:2015-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0361071962085U0001X
WAMD604848942085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
No2085U0001XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Ultrasound
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA2038328Medicaid
H58750Medicare UPIN
ILH58750Medicare UPIN
ILIL3270268Medicare PIN
WA2038328Medicaid
IL6447860011Medicare NSC
WAP01392944Medicare PIN
WAG8931463Medicare PIN
WAG8931465Medicare PIN
WAG8931462Medicare PIN