Provider Demographics
NPI:1376569681
Name:MARTIN, KIMBERLY A (MD)
Entity Type:Individual
Prefix:DR
First Name:KIMBERLY
Middle Name:A
Last Name:MARTIN
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 1:1705 E BROADWAY STE 300
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA
Mailing Address - State:MO
Mailing Address - Zip Code:65201-7167
Mailing Address - Country:US
Mailing Address - Phone:573-817-0810
Mailing Address - Fax:573-817-1790
Practice Address - Street 1:1705 E BROADWAY STE 300
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:MO
Practice Address - Zip Code:65201-7167
Practice Address - Country:US
Practice Address - Phone:573-817-0810
Practice Address - Fax:573-817-1790
Is Sole Proprietor?:No
Enumeration Date:2006-07-14
Last Update Date:2008-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO120024207SG0201X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207SG0201XAllopathic & Osteopathic PhysiciansMedical GeneticsClinical Genetics (M.D.)
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO204739007Medicaid
G36768Medicare UPIN
160046386Medicare PIN
MO204739007Medicaid