Provider Demographics
NPI:1518930189
Name:KIMURA, KEIKO (MD)
Entity Type:Individual
Prefix:
First Name:KEIKO
Middle Name:
Last Name:KIMURA
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 95000-2454
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19195-2454
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:141 S CENTRAL AVE
Practice Address - Street 2:SUITE 102
Practice Address - City:HARTSDALE
Practice Address - State:NY
Practice Address - Zip Code:10530-2319
Practice Address - Country:US
Practice Address - Phone:914-997-1200
Practice Address - Fax:914-997-2418
Is Sole Proprietor?:No
Enumeration Date:2006-02-13
Last Update Date:2012-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY237438207RG0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0300XAllopathic & Osteopathic PhysiciansInternal MedicineGeriatric Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02852260Medicaid
110005984Medicare ID - Type Unspecified
NY02852260Medicaid