Provider Demographics
NPI:1619944857
Name:MIDDLETON, KIMBERLY (MD)
Entity Type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:
Last Name:MIDDLETON
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 1:4170 LAVON DR STE 146
Mailing Address - Street 2:
Mailing Address - City:GARLAND
Mailing Address - State:TX
Mailing Address - Zip Code:75040-2975
Mailing Address - Country:US
Mailing Address - Phone:972-495-7224
Mailing Address - Fax:972-495-2224
Practice Address - Street 1:4170 LAVON DR STE 146
Practice Address - Street 2:
Practice Address - City:GARLAND
Practice Address - State:TX
Practice Address - Zip Code:75040-2975
Practice Address - Country:US
Practice Address - Phone:972-495-7224
Practice Address - Fax:708-756-4026
Is Sole Proprietor?:No
Enumeration Date:2006-03-07
Last Update Date:2021-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036103921207QA0505X
TXS4192207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No207QA0505XAllopathic & Osteopathic PhysiciansFamily MedicineAdult Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
KM086980OtherCHAMPUS-CHAMPUS
MI484049210Medicaid
080H262390OtherBLUE CROSS-BLUE CROSS
KM086980OtherCOMMERCIAL-COMMERCIAL NUMBER
H79609Medicare UPIN
MI484049210Medicaid