Provider Demographics
NPI:1326262866
Name:KIMBALL, BAYLEN GREGORY (MD)
Entity Type:Individual
Prefix:DR
First Name:BAYLEN
Middle Name:GREGORY
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 1:312 SAWGRASS LN
Mailing Address - Street 2:
Mailing Address - City:BROUSSARD
Mailing Address - State:LA
Mailing Address - Zip Code:70518-6149
Mailing Address - Country:US
Mailing Address - Phone:337-856-4653
Mailing Address - Fax:337-232-5384
Practice Address - Street 1:2900 MOSS ST STE F
Practice Address - Street 2:
Practice Address - City:LAFAYETTE
Practice Address - State:LA
Practice Address - Zip Code:70501-1268
Practice Address - Country:US
Practice Address - Phone:337-232-1103
Practice Address - Fax:337-232-5384
Is Sole Proprietor?:No
Enumeration Date:2007-04-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA01540174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1338044Medicaid
LA1338044Medicaid
LA5L645B718Medicare ID - Type UnspecifiedPART B