Provider Demographics
NPI:1366646820
Name:DODD, KIMBERLY A (MD)
Entity Type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:A
Last Name:DODD
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 1:111 BREWSTER STREET
Mailing Address - Street 2:
Mailing Address - City:PAWTUCKET
Mailing Address - State:RI
Mailing Address - Zip Code:02860-4400
Mailing Address - Country:US
Mailing Address - Phone:401-729-3469
Mailing Address - Fax:401-729-2541
Practice Address - Street 1:150 CHESTNUT ST STE 4
Practice Address - Street 2:
Practice Address - City:PROVIDENCE
Practice Address - State:RI
Practice Address - Zip Code:02903-4649
Practice Address - Country:US
Practice Address - Phone:833-229-0957
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-06-11
Last Update Date:2020-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA232516207RG0300X
RIMD13173207RG0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0300XAllopathic & Osteopathic PhysiciansInternal MedicineGeriatric Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
RIKD79114Medicaid
RI000137802OtherMEDICARE PTAN