Provider Demographics
NPI:1619009693
Name:KIMMETH, MAUREEN JUDITH (OD)
Entity Type:Individual
Prefix:DR
First Name:MAUREEN
Middle Name:JUDITH
Last Name:KIMMETH
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:701 PENNSYLVANIA AVE NW
Mailing Address - Street 2:
Mailing Address - City:WASHINGTON
Mailing Address - State:DC
Mailing Address - Zip Code:20004-2608
Mailing Address - Country:US
Mailing Address - Phone:202-783-5318
Mailing Address - Fax:202-783-5319
Practice Address - Street 1:801 PENNSYLVANIA AVE NW
Practice Address - Street 2:STE 4A
Practice Address - City:WASHINGTON
Practice Address - State:DC
Practice Address - Zip Code:20004-2615
Practice Address - Country:US
Practice Address - Phone:202-783-5318
Practice Address - Fax:202-783-5319
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-12
Last Update Date:2019-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DC1000016152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
DC0019Medicaid
DC0019Medicaid