Provider Demographics
NPI:1295826873
Name:KIMBALL, ROBERT O (MD)
Entity Type:Individual
Prefix:DR
First Name:ROBERT
Middle Name:O
Last Name:KIMBALL
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:826 WASHINGTON ST
Mailing Address - Street 2:
Mailing Address - City:WATERTOWN
Mailing Address - State:NY
Mailing Address - Zip Code:13601-4063
Mailing Address - Country:US
Mailing Address - Phone:315-782-1505
Mailing Address - Fax:315-782-2316
Practice Address - Street 1:826 WASHINGTON ST
Practice Address - Street 2:
Practice Address - City:WATERTOWN
Practice Address - State:NY
Practice Address - Zip Code:13601-4063
Practice Address - Country:US
Practice Address - Phone:315-782-1505
Practice Address - Fax:315-782-2316
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-27
Last Update Date:2017-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY168706208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01345064Medicaid
NY01345064Medicaid
NYF30053Medicare UPIN