Provider Demographics
NPI:1578589842
Name:KELLY L WIMBERLY MD PA
Entity Type:Organization
Organization Name:KELLY L WIMBERLY MD PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:KELLY
Authorized Official - Middle Name:L
Authorized Official - Last Name:WIMBERLY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:972-239-4441
Mailing Address - Street 1:17101 PRESTON RD
Mailing Address - Street 2:SUITE 200
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75248-1331
Mailing Address - Country:US
Mailing Address - Phone:972-239-4441
Mailing Address - Fax:972-239-1597
Practice Address - Street 1:17101 PRESTON RD
Practice Address - Street 2:SUITE 200
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75248-1331
Practice Address - Country:US
Practice Address - Phone:972-239-4441
Practice Address - Fax:972-239-1597
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-13
Last Update Date:2008-07-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXJ3002207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXDH1426OtherMEDICARE RR GROUP NUMBER
TXP00474586OtherMEDICARE RR PIN
TX8C6319Medicare ID - Type Unspecified
TX00407XMedicare ID - Type Unspecified
TXP00474586OtherMEDICARE RR PIN