Provider Demographics
NPI:1437189305
Name:KIMBELL, EARL S III (DO)
Entity Type:Individual
Prefix:DR
First Name:EARL
Middle Name:S
Last Name:KIMBELL
Suffix:III
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 130
Mailing Address - Street 2:
Mailing Address - City:SAN FIDEL
Mailing Address - State:NM
Mailing Address - Zip Code:87049-0130
Mailing Address - Country:US
Mailing Address - Phone:505-552-5300
Mailing Address - Fax:505-552-5828
Practice Address - Street 1:80 B VETERANS BLVD
Practice Address - Street 2:I-40, EXIT 102
Practice Address - City:ACOMA
Practice Address - State:NM
Practice Address - Zip Code:87034
Practice Address - Country:US
Practice Address - Phone:505-552-5300
Practice Address - Fax:505-552-5828
Is Sole Proprietor?:No
Enumeration Date:2006-07-04
Last Update Date:2015-06-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ3489204D00000X
MO2010023062207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No204D00000XAllopathic & Osteopathic PhysiciansNeuromusculoskeletal Medicine & OMM
Provider Identifiers
StateIdentifier IDID TypeIssuer
NMH3451Medicaid
NM320070Medicare Oscar/Certification
MO132300137Medicare PIN
P00852010OtherRAILROAD MEDICARE-GROUP CB9013
AZH15187Medicare UPIN
431560263OtherTRICARE WEST