Provider Demographics
NPI:1225024458
Name:KIMBALL, LIANN H (OD)
Entity Type:Individual
Prefix:DR
First Name:LIANN
Middle Name:H
Last Name:KIMBALL
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1449 OLD WATERBURY RD
Mailing Address - Street 2:SUITE 304
Mailing Address - City:SOUTHBURY
Mailing Address - State:CT
Mailing Address - Zip Code:06488-3926
Mailing Address - Country:US
Mailing Address - Phone:203-267-2020
Mailing Address - Fax:203-267-2021
Practice Address - Street 1:1449 OLD WATERBURY RD
Practice Address - Street 2:SUITE 304
Practice Address - City:SOUTHBURY
Practice Address - State:CT
Practice Address - Zip Code:06488-3926
Practice Address - Country:US
Practice Address - Phone:203-267-2020
Practice Address - Fax:203-267-2021
Is Sole Proprietor?:No
Enumeration Date:2005-09-22
Last Update Date:2008-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT001038152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
T23291Medicare UPIN