Provider Demographics
NPI:1407941842
Name:DONG, KIMBERLY (MS, RD)
Entity Type:Individual
Prefix:MISS
First Name:KIMBERLY
Middle Name:
Last Name:DONG
Suffix:
Gender:F
Credentials:MS, RD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:700 HURON AVE #9B
Mailing Address - Street 2:
Mailing Address - City:CAMBRIDGE
Mailing Address - State:MA
Mailing Address - Zip Code:02138
Mailing Address - Country:US
Mailing Address - Phone:617-966-6577
Mailing Address - Fax:
Practice Address - Street 1:3 THORNTON STREET
Practice Address - Street 2:
Practice Address - City:NEWTON
Practice Address - State:MA
Practice Address - Zip Code:02458
Practice Address - Country:US
Practice Address - Phone:617-332-2777
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA2011133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA478989OtherTUFTS HEALTH PLAN
MAAA4501OtherHARVARD PILGRIM HEALTH CA
MADO-MT0798Medicare ID - Type Unspecified