Provider Demographics
NPI:1497751663
Name:PERSHALL, KIM E (MD)
Entity Type:Individual
Prefix:DR
First Name:KIM
Middle Name:E
Last Name:PERSHALL
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3811 24TH STREET
Mailing Address - Street 2:
Mailing Address - City:LUBBOCK
Mailing Address - State:TX
Mailing Address - Zip Code:79410-1813
Mailing Address - Country:US
Mailing Address - Phone:806-796-0202
Mailing Address - Fax:806-796-0496
Practice Address - Street 1:3811 24TH STREET
Practice Address - Street 2:
Practice Address - City:LUBBOCK
Practice Address - State:TX
Practice Address - Zip Code:79410-1813
Practice Address - Country:US
Practice Address - Phone:806-796-0202
Practice Address - Fax:806-796-0496
Is Sole Proprietor?:No
Enumeration Date:2005-06-22
Last Update Date:2011-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXJ3574174400000X, 207Y00000X, 207YS0123X, 207YX0602X
NM86103174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngology
No174400000XOther Service ProvidersSpecialist
No207YS0123XAllopathic & Osteopathic PhysiciansOtolaryngologyFacial Plastic Surgery
No207YX0602XAllopathic & Osteopathic PhysiciansOtolaryngologyOtolaryngic Allergy
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX121351100OtherFIRSTCARE
TX034333701Medicaid
TX8P8420OtherBCBS TX
NM37234Medicaid
TX8F21125OtherMEDICARE PTAN
TX148127701OtherMEDICAID GROUP
TX040007969OtherRAILROAD MEDICARE
TX8P8420OtherBCBS TX