Provider Demographics
NPI:1336109990
Name:PRATER, KIMBERLEY (MD)
Entity Type:Individual
Prefix:
First Name:KIMBERLEY
Middle Name:
Last Name:PRATER
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:KIMBERLEY
Other - Middle Name:
Other - Last Name:ALEXANDER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:PO BOX 3262
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:MO
Mailing Address - Zip Code:65808-3262
Mailing Address - Country:US
Mailing Address - Phone:417-885-3888
Mailing Address - Fax:417-881-7268
Practice Address - Street 1:3850 S NATIONAL AVE
Practice Address - Street 2:SUITE 300
Practice Address - City:SPRINGFIELD
Practice Address - State:MO
Practice Address - Zip Code:65807-5287
Practice Address - Country:US
Practice Address - Phone:417-269-6170
Practice Address - Fax:417-269-6992
Is Sole Proprietor?:No
Enumeration Date:2006-03-27
Last Update Date:2010-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO364182085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO1256OtherBLUE
MOP00807644OtherMEDICARE RAILROAD
MO300035139OtherRRR MEDICARE
MO202564407Medicaid
AR116201001Medicaid
AR116201001Medicaid
MO202564407Medicaid
MO004010242Medicare PIN