Provider Demographics
NPI:1528022084
Name:KIMSEY, L. MARK (MD)
Entity Type:Individual
Prefix:DR
First Name:L. MARK
Middle Name:
Last Name:KIMSEY
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 1:305 E LOGAN ST
Mailing Address - Street 2:
Mailing Address - City:CALDWELL
Mailing Address - State:ID
Mailing Address - Zip Code:83605-4863
Mailing Address - Country:US
Mailing Address - Phone:208-459-2840
Mailing Address - Fax:208-459-3012
Practice Address - Street 1:305 E LOGAN ST
Practice Address - Street 2:
Practice Address - City:CALDWELL
Practice Address - State:ID
Practice Address - Zip Code:83605-4863
Practice Address - Country:US
Practice Address - Phone:208-459-2840
Practice Address - Fax:208-459-3012
Is Sole Proprietor?:Yes
Enumeration Date:2006-04-13
Last Update Date:2024-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDM56542084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID5654-9OtherBLUE CROSS
ID000010004477OtherBLUE SHIELD
CA000390401Medicaid
ID000010004477OtherBLUE SHIELD