Provider Demographics
NPI:1386636009
Name:MCDONALD, KIM L (MD)
Entity Type:Individual
Prefix:DR
First Name:KIM
Middle Name:L
Last Name:MCDONALD
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 1:4585 WASHINGTON ST
Mailing Address - Street 2:SUITE C4
Mailing Address - City:FLORISSANT
Mailing Address - State:MO
Mailing Address - Zip Code:63033-5858
Mailing Address - Country:US
Mailing Address - Phone:314-838-8839
Mailing Address - Fax:314-838-4291
Practice Address - Street 1:4585 WASHINGTON ST
Practice Address - Street 2:SUITE C4
Practice Address - City:FLORISSANT
Practice Address - State:MO
Practice Address - Zip Code:63033-5858
Practice Address - Country:US
Practice Address - Phone:314-838-8839
Practice Address - Fax:314-838-4291
Is Sole Proprietor?:Yes
Enumeration Date:2005-08-18
Last Update Date:2021-07-28
Deactivation Date:2006-03-23
Deactivation Code:
Reactivation Date:2006-04-05
Provider Licenses
StateLicense IDTaxonomies
MOR4E37207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO000014505OtherMEDICARE GROUP #
MO501498406Medicaid
MO000014505OtherMEDICARE GROUP #
MO944544505Medicare PIN