Provider Demographics
NPI:1578545919
Name:KIMBALL, GORDON R (MD)
Entity Type:Individual
Prefix:
First Name:GORDON
Middle Name:R
Last Name:KIMBALL
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 1:9844 S 1300 E
Mailing Address - Street 2:#275
Mailing Address - City:SANDY
Mailing Address - State:UT
Mailing Address - Zip Code:84094-4692
Mailing Address - Country:US
Mailing Address - Phone:801-571-7061
Mailing Address - Fax:801-571-9277
Practice Address - Street 1:9844 S 1300 E
Practice Address - Street 2:#275
Practice Address - City:SANDY
Practice Address - State:UT
Practice Address - Zip Code:84094-4692
Practice Address - Country:US
Practice Address - Phone:801-571-7061
Practice Address - Fax:801-571-9277
Is Sole Proprietor?:Yes
Enumeration Date:2005-11-18
Last Update Date:2008-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT0551110013207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT999-000-116-008Medicaid
UT17640OtherHMO
UTD07287Medicare UPIN
UT17640OtherHMO