Provider Demographics
NPI:1518079623
Name:HUDSPETH, KIMBERLY K (MD)
Entity Type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:K
Last Name:HUDSPETH
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 1:9515 HOLY CROSS LN
Mailing Address - Street 2:
Mailing Address - City:BREESE
Mailing Address - State:IL
Mailing Address - Zip Code:62230-3618
Mailing Address - Country:US
Mailing Address - Phone:618-526-4511
Mailing Address - Fax:618-526-4537
Practice Address - Street 1:205 MUNSTER ST
Practice Address - Street 2:
Practice Address - City:GERMANTOWN
Practice Address - State:IL
Practice Address - Zip Code:62245-1004
Practice Address - Country:US
Practice Address - Phone:618-523-4216
Practice Address - Fax:618-523-7049
Is Sole Proprietor?:No
Enumeration Date:2006-08-31
Last Update Date:2018-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS0431810207R00000X
IL036131870208M00000X, 207R00000X
KS04-31810208M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No208M00000XAllopathic & Osteopathic PhysiciansHospitalist
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS200404330DMedicaid
KSI59686Medicare UPIN
KS200404330DMedicaid