Provider Demographics
NPI:1235199753
Name:MICUS, KIMBERLY L (MD)
Entity Type:Individual
Prefix:DR
First Name:KIMBERLY
Middle Name:L
Last Name:MICUS
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 1:1600 PROVIDENCE DR
Mailing Address - Street 2:
Mailing Address - City:WACO
Mailing Address - State:TX
Mailing Address - Zip Code:76707-2261
Mailing Address - Country:US
Mailing Address - Phone:254-313-4200
Mailing Address - Fax:254-313-4549
Practice Address - Street 1:120 HILLCREST MEDICAL BLVD
Practice Address - Street 2:SUITE 300
Practice Address - City:WACO
Practice Address - State:TX
Practice Address - Zip Code:76712-8948
Practice Address - Country:US
Practice Address - Phone:254-313-6500
Practice Address - Fax:254-313-6599
Is Sole Proprietor?:No
Enumeration Date:2006-03-27
Last Update Date:2017-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXK2963207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX037038904Medicaid
TX0370389-01Medicaid
TX160050362OtherRR/MEDICARE
TX80314NOtherBLUE SHIELD
TX037038904Medicaid
TX0370389-01Medicaid
TXG84631Medicare UPIN