Provider Demographics
NPI:1548212152
Name:BOCKMON, KIMBALL W (MD)
Entity Type:Individual
Prefix:
First Name:KIMBALL
Middle Name:W
Last Name:BOCKMON
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:PO BOX 26726
Mailing Address - Street 2:
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78755-0726
Mailing Address - Country:US
Mailing Address - Phone:512-407-8686
Mailing Address - Fax:512-421-4489
Practice Address - Street 1:4515 SETON CENTER PKWY #220
Practice Address - Street 2:
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78759-5784
Practice Address - Country:US
Practice Address - Phone:512-338-8388
Practice Address - Fax:512-338-8426
Is Sole Proprietor?:No
Enumeration Date:2006-05-16
Last Update Date:2010-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXF6455207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX114865205Medicaid
TX114865206Medicaid
TX114865206Medicaid
TX8K7465Medicare PIN
TX114865205Medicaid