Provider Demographics
NPI:1619059201
Name:UDELL, KIMBERLY (DO)
Entity Type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:
Last Name:UDELL
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3602 MATLOCK RD
Mailing Address - Street 2:206
Mailing Address - City:ARLINGTON
Mailing Address - State:TX
Mailing Address - Zip Code:76015
Mailing Address - Country:US
Mailing Address - Phone:817-468-1506
Mailing Address - Fax:817-468-1520
Practice Address - Street 1:3602 MATLOCK RD STE 206
Practice Address - Street 2:
Practice Address - City:ARLINGTON
Practice Address - State:TX
Practice Address - Zip Code:76015-3600
Practice Address - Country:US
Practice Address - Phone:817-468-1506
Practice Address - Fax:817-468-1520
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-20
Last Update Date:2019-05-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXL1225207VG0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207VG0400XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX651198393OtherEMPLOYER TX ID NUMBER
TX8P5630OtherBLUE CROSS BLUE SHIELD
TX10029987OtherAMERIGROUP
TX165666201Medicaid
TX8P5630OtherBLUE CROSS BLUE SHIELD