Provider Demographics
NPI:1588616775
Name:MOONEY-MCNULTY, KIMBERLY (MD)
Entity Type:Individual
Prefix:MRS
First Name:KIMBERLY
Middle Name:
Last Name:MOONEY-MCNULTY
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:669 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:WAKEFIELD
Mailing Address - State:MA
Mailing Address - Zip Code:01880-5200
Mailing Address - Country:US
Mailing Address - Phone:781-245-5200
Mailing Address - Fax:781-246-3932
Practice Address - Street 1:669 MAIN ST
Practice Address - Street 2:
Practice Address - City:WAKEFIELD
Practice Address - State:MA
Practice Address - Zip Code:01880-5200
Practice Address - Country:US
Practice Address - Phone:781-245-5200
Practice Address - Fax:781-246-3932
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-16
Last Update Date:2015-07-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA150574207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA3182606Medicaid
MA3182606Medicaid
A28589Medicare ID - Type Unspecified