Provider Demographics
NPI:1447240155
Name:OVERDECK, KIMBERLEE H (MD)
Entity Type:Individual
Prefix:DR
First Name:KIMBERLEE
Middle Name:H
Last Name:OVERDECK
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:LAUREN
Other - Middle Name:KIMBERLEE
Other - Last Name:HORTON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:111 OAKWOOD RD
Mailing Address - Street 2:
Mailing Address - City:EAST PEORIA
Mailing Address - State:IL
Mailing Address - Zip Code:61611-1853
Mailing Address - Country:US
Mailing Address - Phone:309-740-4272
Mailing Address - Fax:
Practice Address - Street 1:1112 SHIPMAN LANE
Practice Address - Street 2:
Practice Address - City:MCLEAN
Practice Address - State:VA
Practice Address - Zip Code:22101-2137
Practice Address - Country:US
Practice Address - Phone:703-556-6466
Practice Address - Fax:703-556-8881
Is Sole Proprietor?:No
Enumeration Date:2005-10-24
Last Update Date:2023-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036-1342262085R0202X
MDD00617842085R0202X
VA01012406482085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA1447240155Medicaid
LA1452068Medicaid
LA1452068Medicaid
VA1447240155Medicaid
014320D23Medicare PIN