Provider Demographics
NPI:1346248937
Name:KIMBALL, LAWRENCE DUSTIN III (DO)
Entity Type:Individual
Prefix:
First Name:LAWRENCE
Middle Name:DUSTIN
Last Name:KIMBALL
Suffix:III
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:451 HIDDEN MEADOWS DR
Mailing Address - Street 2:SUITE 120
Mailing Address - City:HILLSDALE
Mailing Address - State:MI
Mailing Address - Zip Code:49242-9812
Mailing Address - Country:US
Mailing Address - Phone:517-437-0010
Mailing Address - Fax:517-437-0319
Practice Address - Street 1:451 HIDDEN MEADOWS DR
Practice Address - Street 2:SUITE 120
Practice Address - City:HILLSDALE
Practice Address - State:MI
Practice Address - Zip Code:49242-9812
Practice Address - Country:US
Practice Address - Phone:517-437-0010
Practice Address - Fax:517-437-0319
Is Sole Proprietor?:Yes
Enumeration Date:2005-07-08
Last Update Date:2014-04-14
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MI5101010860207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI0153000035OtherBCBS
MI2935031Medicaid
MI102060OtherGLHP
MI080071137OtherMEDICARE-RAILROAD
MIP89542OtherBCN
MI0120040OtherPHP
MI080071137OtherMEDICARE-RAILROAD
MI102060OtherGLHP