Provider Demographics
NPI:1548238058
Name:KIMBRELL, MARK (MD)
Entity Type:Individual
Prefix:DR
First Name:MARK
Middle Name:
Last Name:KIMBRELL
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:328 ULUNIU ST
Mailing Address - Street 2:SUITE 103
Mailing Address - City:KAILUA
Mailing Address - State:HI
Mailing Address - Zip Code:96734-2547
Mailing Address - Country:US
Mailing Address - Phone:808-263-3020
Mailing Address - Fax:808-263-3723
Practice Address - Street 1:328 ULUNIU ST
Practice Address - Street 2:SUITE 103
Practice Address - City:KAILUA
Practice Address - State:HI
Practice Address - Zip Code:96734-2547
Practice Address - Country:US
Practice Address - Phone:808-263-3020
Practice Address - Fax:808-263-3723
Is Sole Proprietor?:Yes
Enumeration Date:2006-03-09
Last Update Date:2011-05-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
HIMD-5448207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
HI059806-01Medicaid
HI059806-01Medicaid
F67394Medicare UPIN