Provider Demographics
NPI:1629058474
Name:ZIMMERMAN, KENT G (MD)
Entity Type:Individual
Prefix:
First Name:KENT
Middle Name:G
Last Name:ZIMMERMAN
Suffix:
Gender:M
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:PO BOX 42210
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85080-2210
Mailing Address - Country:US
Mailing Address - Phone:623-889-7403
Mailing Address - Fax:623-889-7407
Practice Address - Street 1:1255 W WASHINGTON ST
Practice Address - Street 2:
Practice Address - City:TEMPE
Practice Address - State:AZ
Practice Address - Zip Code:85281-1210
Practice Address - Country:US
Practice Address - Phone:602-685-5211
Practice Address - Fax:623-889-7407
Is Sole Proprietor?:No
Enumeration Date:2006-01-18
Last Update Date:2013-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ14079207ZP0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ZP0102XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology & Clinical Pathology
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZZWMBNX09Medicare PIN
AZZ22WCHTT1TMedicare PIN
F24846Medicare UPIN