Provider Demographics
NPI:1407296593
Name:KIMBRO, PAUL DAVIS (OD)
Entity Type:Individual
Prefix:DR
First Name:PAUL
Middle Name:DAVIS
Last Name:KIMBRO
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:735 JOHN R RD STE 150
Mailing Address - Street 2:
Mailing Address - City:TROY
Mailing Address - State:MI
Mailing Address - Zip Code:48083-5859
Mailing Address - Country:US
Mailing Address - Phone:248-588-9300
Mailing Address - Fax:
Practice Address - Street 1:29350 SOUTHFIELD RD
Practice Address - Street 2:
Practice Address - City:SOUTHFIELD
Practice Address - State:MI
Practice Address - Zip Code:48076-2011
Practice Address - Country:US
Practice Address - Phone:248-647-9790
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-07-03
Last Update Date:2019-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4901004778152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI12602113OtherCAQH
MI1407296593Medicaid