Provider Demographics
NPI:1508887621
Name:SHANKS, KIMBERLEY P (MD)
Entity Type:Individual
Prefix:
First Name:KIMBERLEY
Middle Name:P
Last Name:SHANKS
Suffix:
Gender:F
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:PO BOX 742616
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30374-2616
Mailing Address - Country:US
Mailing Address - Phone:770-219-8420
Mailing Address - Fax:
Practice Address - Street 1:2510 LIMESTONE PKWY
Practice Address - Street 2:
Practice Address - City:GAINESVILLE
Practice Address - State:GA
Practice Address - Zip Code:30501-2089
Practice Address - Country:US
Practice Address - Phone:770-534-9933
Practice Address - Fax:770-594-8999
Is Sole Proprietor?:No
Enumeration Date:2006-07-22
Last Update Date:2020-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA0578402080P0201X, 207K00000X, 207KA0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207K00000XAllopathic & Osteopathic PhysiciansAllergy & Immunology
No2080P0201XAllopathic & Osteopathic PhysiciansPediatricsPediatric Allergy/Immunology
No207KA0200XAllopathic & Osteopathic PhysiciansAllergy & ImmunologyAllergy
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA58I030003OtherMEDICARE
GA242084536CMedicaid